Author + information
- R. Sacha Bhatia, MD∗ (, )
- Rory B. Weiner, MD,
- for the Echo WISELY Investigators
- ↵∗Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, University of Toronto, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2, Canada
We thank Dr. Lin and colleagues for their insightful comments regarding the Echo WISELY study. The first concern the authors raise is the potential bias among physicians who may have different baseline levels of appropriate use and may service different patient populations. In our study, we did randomize by site and physician type (primary care physician vs. cardiologist) in an effort to reduce institutional and specialty bias. Although we did not have baseline individual appropriateness rates, our large sample size of 179 physicians likely limited this potential bias. Moreover, we did have data from previous studies that we used to determine the a priori sample size calculations for this study (1).
Second, although Dr. Lin and colleagues are correct that approximately 40% of physicians did not log into the detailed feedback reports, we also provided email feedback that the physicians did not have to log into, which simply provided monthly feedback on performance. Although this did not deliver the detailed data that the feedback reports contained, it did include some data for the intervention physicians on their ordering performance.
Dr. Lin and colleagues raise an important concern regarding sustainability of the intervention. We agree that the long-term success of the strategy used in our study will likely require ongoing feedback. This is an area of active investigation, and we are analyzing the impact of discontinuation of the intervention on ordering appropriateness. At present, sustaining the intervention would be labor intensive, but as suggested by Dr. Randolph Martin in the commentary accompanying our study, the development of artificial intelligence and natural language processing tools could certainly help make the assessment of appropriate use much less resource intensive and sustainable (2).
Finally, Dr. Lin and colleagues discuss the development and implementation of diverse interventions to improve ordering appropriateness. Although we agree that multiple strategies may be required to achieve an optimal level of appropriate use, these interventions should be studied in a rigorous manner to ensure their effectiveness before widespread deployment.
Please note: Funding was provided by the Cardiac Care Network of Ontario, the Ontario Ministry of Health and Long Term Care, and the Peter Munk Cardiac Center. Dr. Bhatia is supported by a clinician scientist award from the Heart and Stroke Foundation and the F.M. Hill Chair in Health Systems Solutions at Women’s College Hospital. Both 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.
- 2017 American College of Cardiology Foundation