Background: Transthoracic echocardiogram (TTE) is a frequently used cardiovascular imaging test for hospitalized patients especially those with chronic heart failure. Over the past two decades, TTE orders increased at a rate of about 5-8% per year. A large component of this is repeat TTE orders, defined as orders done within one year of a prior TTE. Repeat orders represent approximately 25% of all TTE orders. However, only a third of repeat orders are considered clinically appropriate. One study reported that 32% of repeat TTEs did not demonstrate any change resulting in unnecessary testing. Efforts should be made to reduce repeat studies, which may lead to improved resource allocation. The goal of our study was to leverage the electronic medical record (EMR) to reduce repeat TTEs and study the impact of this reduction on important clinical metrics.
Methods: Our intervention to reduce repeat TTE orders was to create a best practice alert (BPA) within the EMR for all hospitals within the Johns Hopkins Health System (JHHS). The BPA was designed to trigger when a clinician orders a TTE on a hospitalized patient who already had a TTE in the system within the prior 3 months (inpatient or outpatient). Notably, the BPA excludes orders placed on patients admitted to the cardiac care unit and cardiovascular surgical intensive care unit. The BPA displays the findings from the most recent TTE and asks the clinician if they would like to continue with the order or cancel it. If a provider opts to continue with the order, a free text reason must be entered to explain the rationale for continuing with the order.
Results: In the three months prior to the intervention, approximately 700 repeat TTEs were ordered per month on average within the Johns Hopkins Healthcare System (JHHS). Since initiation of the BPA, 65.7% of clinicians chose to continue the order, and 34.3% opted to discontinue. Readmission rates and length of stay (LOS) served as balancing measures and were compared for patients who underwent repeat TTE vs. those who did have repeat testing. Initial data demonstrates that patients who underwent repeat TTE testing had a 20% 30-day readmission rate as compared to 19% readmission rate in those who did not have repeat testing (p-value 0.88). The average LOS for patients who underwent repeat TTE was 11.4 days vs. an average LOS of 9.3 days for patients who did not undergo repeat TTE (p-value 0.41).
Conclusions: The BPA designed within the EMR successfully reduced repeat TTEs without leading to increased readmissions or LOS. Future directions include evaluating comments entered by providers for the reasons to override the BPA to identify additional areas for intervention. By eliminating non-clinically indicated repeat TTEs, sonographers and cardiologists are able to use their time more efficiently and hospitals can reallocate resources better to improve patient care.