Implementing a Continuous Quality Improvement Program in a High-Volume Clinical Echocardiography Laboratory: Improving Care for Patients With Aortic Stenosis.
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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.
Subjectaortic valve stenosis
Aortic Valve Stenosis
Patient Care Team
Practice Patterns, Physicians'
Predictive Value of Tests
Quality Indicators, Health Care
Reproducibility of Results
Severity of Illness Index
Published Version (Please cite this version)10.1161/CIRCIMAGING.115.003708
Publication InfoArmour, A; Douglas, Pamela Susan; Harrison, JK; Horan, Seanna; Kisslo, Joseph Andrew; Minter, Stephanie; ... 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.
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Ursula Geller Professor for Research in Cardiovascular Disease, in the School of Medicine
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
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, ac
Adjunct Associate Professor in the Department of Medicine
Dr. Zainab Samad is 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 training in cardiovascular imaging, specifically in clinical echocardiography, cardiac MRI and SPECT-myocardi
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
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