Author + information
- Shen Lin, MD,
- Heng Zhang, MD, PhD and
- Zhe Zheng, MD, PhD∗ ()
- ↵∗National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing 100037, People’s Republic of China
We read with interest the report in which Bhatia et al. (1) investigated the impact of an appropriate use criteria (AUC)−based educational intervention on the ordering of outpatient transthoracic echocardiography (TTE) by cardiologists and primary care providers. This is an excellent randomized trial, and the educational and feedback intervention was observed to reduce the use of rarely appropriate TTE (1).
Notably, the stratified randomization based on hospital site and physician specialty raised some concerns. Eliminating bias of physician baseline appropriateness, malleability, and patient baseline characteristics among 2 groups was critical to the credibility of this trial. Thus, a stratified randomization including the baseline appropriateness of the physician may be a proper approach. Simultaneously, the attitude of the physicians toward AUC and patient baseline characteristics should be collected and reported to verify the effectiveness of randomization, which may make the outcome convincing (2).
In addition, the investigators demonstrated that nearly 40% of physicians in the intervention group failed to be intervened by educational material or feedback report, indicating that it is necessary to be cautious about the intervention implementation (1). Because the intensity of intervention is of great importance in comprehending the outcome, the detailed information of the physicians who were not successfully intervened should be analyzed.
Because the effect of the specific intervention was reported as not sustained in another time series analysis, we strongly agree with the opinion in the limitations of the paper that the sustainability of the impact of this type of intervention needs further study (1,3). However, in realistic clinical practice, diverse interventions should be developed and be consecutively implemented to gradually establish regular audit and feedback mechanisms, which may finally improve specific medical test use and treatment appropriateness.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. P.K. Shah, MD, served as Guest Editor for this paper.
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