Implementing a Continuous Quality Improvement Program in a High-Volume Clinical Echocardiography Laboratory: Improving Care for Patients With Aortic Stenosis.
Abstract
BACKGROUND: The management of aortic stenosis rests on accurate echocardiographic
diagnosis. Hence, it was chosen as a test case to examine the utility of continuous
quality improvement (CQI) approaches to increase echocardiographic data accuracy and
reliability. A novel, multistep CQI program was designed and prospectively used to
investigate whether it could minimize the difference in aortic valve mean gradients
reported by echocardiography when compared with cardiac catheterization. METHODS AND
RESULTS: The Duke Echo Laboratory compiled a multidisciplinary CQI team including
4 senior sonographers and MD faculty to develop a mapped CQI process that incorporated
Intersocietal Accreditation Commission standards. Quarterly, the CQI team reviewed
all moderate- or greater-severity aortic stenosis echocardiography studies with concomitant
catheterization data, and deidentified individual and group results were shared at
meetings attended by cardiologists and sonographers. After review of 2011 data, the
CQI team proposed specific amendments implemented over 2012: the use of nontraditional
imaging and Doppler windows as well as evaluation of aortic gradients by a second
sonographer. The primary outcome measure was agreement between catheterization- and
echocardiography-derived mean gradients calculated by using the coverage probability
index with a prespecified acceptable echocardiography-catheterization difference of
<10 mm Hg in mean gradient. Between January 2011 and January 2014, 2093 echocardiograms
reported moderate or greater aortic stenosis. Among cases with available catheterization
data pre- and post-CQI, the coverage probability index increased from 54% to 70% (P=0.03;
98 cases, year 2011; 70 cases, year 2013). The proportion of patients referred for
invasive valve hemodynamics decreased from 47% pre-CQI to 19% post-CQI (P<0.001).
CONCLUSIONS: A laboratory practice pattern that was amenable to reform was identified,
and a multistep modification was designed and implemented that produced clinically
valuable performance improvements. The new protocol improved aortic stenosis mean
gradient agreement between echocardiography and catheterization and was associated
with a measurable decrease in referrals of patients for invasive studies.
Type
Journal articleSubject
aortic valve stenosiscatheterization
echocardiography
image acquisition
image quality
quality improvement
Aortic Valve
Aortic Valve Stenosis
Cardiac Catheterization
Critical Pathways
Echocardiography, Doppler
Feasibility Studies
Hemodynamics
Hospitals, High-Volume
Humans
Observer Variation
Patient Care Team
Practice Patterns, Physicians'
Predictive Value of Tests
Program Evaluation
Prospective Studies
Quality Improvement
Quality Indicators, Health Care
Reproducibility of Results
Severity of Illness Index
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https://hdl.handle.net/10161/15611Published Version (Please cite this version)
10.1161/CIRCIMAGING.115.003708Publication Info
Samad, Zainab; Minter, Stephanie; Armour, Alicia; Tinnemore, Amanda; Sivak, Joseph
A; Sedberry, Brenda; ... Velazquez, Eric J (2016). Implementing a Continuous Quality Improvement Program in a High-Volume Clinical Echocardiography
Laboratory: Improving Care for Patients With Aortic Stenosis. Circ Cardiovasc Imaging, 9(3). 10.1161/CIRCIMAGING.115.003708. Retrieved from https://hdl.handle.net/10161/15611.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Pamela Susan Douglas
Ursula Geller Distinguished Professor of Research in Cardiovascular Diseases
Pamela S Douglas MD is the Ursula Geller Professor of Research in Cardiovascular Diseases
in the Department of Medicine at Duke University and Director of the Multimodality
Imaging Program at Duke Clinical Research Institute. During her 30+ years of experience
she has led several landmark multicenter government studies and pivotal industry clinical
trials along with outcomes research studies. She is renowned for her scientific and
policy work in improving the quality and appropriateness
John Kevin Harrison
Professor of Medicine
Joseph Andrew Kisslo
Professor of Medicine
Dr. Kisslo's research has centered around the development and initial application
of new ultrasound imaging devices. Focussed principally on morphologic diagnosis in
the early years, the work has become progressively more physiologic in it's orientation.
After more than two decades there are now 300 original research papers, several textbooks
and other materials. Dr. Kisslo has distinguished himself as the first to use phased
array ultrasound imaging in the human body and, according
Zainab Samad
Adjunct Associate Professor in the Department of Medicine
Dr. Zainab Samad is chairwoman of the Department of Medicine at Aga Khan University
(AKU) in Pakistan and currently serves as an Adjunct Associate Professor of Medicine
at Duke University. She attended Medical School at the Aga Khan University Medical
College in Karachi, Pakistan and thereafter completed her residency training in Internal
Medicine and fellowship in Cardiology at Duke University Medical Center in Durham,
North Carolina. Additionally, she completed advanced tra
Eric J. Velazquez
Adjunct Professor in the Department of Medicine
LeadershipEric J. Velazquez, MD, is a Professor of Medicine with tenure at Duke University.
As section chief for Cardiovascular Imaging in the Division of Cardiology and director
of the Cardiac Diagnostic Unit and Echocardiography Laboratories for Duke University
Health System, he coordinates a high-volume enterprise and an outstanding group of
clinician-investigators and clinical staff who make important contributions across
patient care, research and educational
This author no longer has a Scholars@Duke profile, so the information shown here reflects
their Duke status at the time this item was deposited.
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