Article Text


Original research article
A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging
  1. David E Winchester1,2,
  2. Carsten Schmalfuss1,2,
  3. Christian D Helfrich3 and
  4. Rebecca J Beyth4,5
  1. 1 Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA
  2. 2 Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
  3. 3 VA Puget Sound Health Care System, Seattle, Washington, USA
  4. 4 Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VA Medical Center, Gainesville, Florida, USA
  5. 5 Division of General Internal Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
  1. Correspondence to Dr David E Winchester; david.winchester{at}


Objective Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI.

Methods We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention.

Results A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI.

Conclusions In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.

  • appropriate use criteria
  • myocardial perfusion imaging
  • quality improvement
  • de-implementation

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  • Contributors DEW: conception, design and drafting of the work. All authors: acquisition, analysis, interpretation of data for the work; revising it critically for important intellectual content; final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was supported by Veterans Integrated Service Network-8 Innovation Grant and with resources of the Malcom Randall VAMC. Additional funding was provided by an unrestricted grant from the Florida Heart Research Institute (Miami, FL).

  • Competing interests None declared.

  • Patient consent Not obtained because the study was performed under waiver of informed consent provided by the IRB.

  • Ethics approval University of Florida Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Unpublished data are available from author DEW with an approved data sharing agreement between any requesting party and the US government.

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