In 2016 the American Society of Nuclear Cardiology (ASNC) put its own spin on the Choosing Wisely Champions program by launching the Choosing Wisely Challenge – an effort to identify innovative and creative solutions in nuclear cardiology that supported the organization’s Choosing Wisely® recommendations.
All ASNC members were encouraged to apply, and three finalists were selected to present their projects at the society’s annual meeting in fall 2016. Attendees, along with a panel of judges comprising ASNC leadership and an ABIM Foundation representative, determined the winners:
First place: A Novel Outpatient Pathway for Chest Pain Visits to the Emergency Department (pdf) by Felix Krainski, MD; Besiana Liti, DO; and Lane Duvall, MD
Second place: Education to Reduce Rarely Appropriate Myocardial Perfusion Imaging (pdf) by David E. Winchester, MD, MS, FASNC; David C. Wymer, MD; Anita Wokhlu, MD; Vicente Taasan, MD; Christian Helfrich, PhD; Susan Stinson, RN; and Rebecca J. Beyth, MD, MSc
Third place: Revision of Order Entry for Myocardial Perfusion Imaging (pdf) by Erica Cohen, DO, MPH
“Our study team and collaborators in cardiology and emergency medicine were happy to see concrete validation of our efforts. But more importantly, it was gratifying to see that we could take care of our patients more efficiently and in a manner that was more satisfactory to the patient, but still do it safely,” said Dr. Duvall, one of the members of the first place team.
Dr. Duvall says chest pain is a common complaint for emergency department (ED) visits and results in considerable health care expense and length of stay. However, for certain “low-risk” patients, the amount of time spent in the ED and associated interventions may be unnecessary.
“My initial interest stemmed from my research efforts to decrease radiation exposure during myocardial perfusion imaging. Our previous work focused on new imaging technology and novel stress protocols, but we also realized that not performing unnecessary tests could also make a large impact on radiation exposure reduction,” said Dr. Duvall.
Along with his colleagues, Dr. Duvall developed an alternative pathway for low-risk patients that included an outpatient stress test and provisional radioisotope injection protocol, as opposed to conducting these services in the ED. Patients qualified as low-risk if they had atypical chest pain, no known coronary artery disease, at least two sets of negative cardiac enzymes, and an overall low risk profile.
This work aligns with several ASNC Choosing Wisely recommendations advocating for reduced imaging or testing whenever possible.
“Choosing Wisely provides a very simple and straightforward approach to decreasing unnecessary care when it comes to nuclear cardiology procedures. These guidelines can be easily followed by specialists and general practitioners alike,” said Dr. Duvall.
Between October 2015 and February 2016, 156 patients at Hartford Hospital underwent the outpatient testing protocol, with 109 patients returning for their follow-up appointments. The project resulted in:
- 72 percent reduction in length of stay in the ED
- 79 percent decrease in financial health care burden across the entire spectrum of payers
- 85 percent reduction in radiation exposure due to the provisional injection protocol
Dr. Duvall and his colleagues say that, while not a formal assessment, they also observed that patients expressed satisfaction with the decreased amount of time spent in the ED. Providers were also happier to have the option to discharge low-risk patients and follow up with them in an outpatient setting, thus reducing their administrative burden of redundant admission and discharge dictations, as well as order writing.
“Discussions of overuse of diagnostic imaging studies have become much more mainstream in the past few years thanks to published Appropriate Use Criteria and campaigns like Choosing Wisely. Much more scrutiny is now placed on ordering tests, and ordering physicians routinely need to go to more effort to justify questionable requests,” said Dr. Duvall.