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INTRODUCTION: Appropriate use criteria (AUC) guide initial transthoracic echocardiogram (TTE) use in outpatient pediatrics. We sought to improve pediatric cardiologist TTE ordering appropriateness (mean AUC score) with a quality improvement initiative. METHODS: The outcome of interest was the prospective AUC score for all initial outpatient TTEs ordered between November 2016 and August 2017, categorized per the AUC: "appropriate" (score 7-9), "may be appropriate" (4-6), "rarely appropriate" (1-3). Interventions included a didactic review of 2014 AUC and participant documentation of AUC criteria for each TTE. Participants met quarterly to evaluate outcome, process, and balancing measures, intervention effectiveness, and to identify and mitigate barriers. RESULTS: Twenty-two pediatric cardiologists participated. TTE appropriateness level before (n = 216) and after (n = 557) intervention was high. There was no significant difference in mean baseline and post-intervention AUC score (7.42 ± 1.87 versus 7.16 ± 2.87, P = 0.1), nor in TTE sensitivity (27% versus 25%, P > 0.1) as a balancing measure. Among baseline studies, 81% were "appropriate," and 6% "rarely appropriate." Among post-intervention studies, 76% were "appropriate," and 11% "rarely appropriate." Barriers identified to implementing AUC include TTE indications not specified by current AUC, expectations of referring provider or parent to perform TTE, consistent provider application of AUC, and ability of AUC to capture comprehensive clinical judgment. CONCLUSIONS: Although the mean AUC appropriateness level was high, we were able to identify significant barriers to the implementation of AUC. Future efforts should focus on the reduction of "rarely appropriate" TTE ordering.
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OBJECTIVES: Evaluative assessment is needed to inform improvement of Part 4 Maintenance of Certification (MOC), a large-scale program that aims to improve physician knowledge, engagement, and skills in quality improvement (QI). We sought to determine if Part 4 MOC participation improves perceived educational and clinical outcomes by piloting a new physician survey. METHODS: We administered a new online survey (MOC Practice, Engagement, Attitude, and Knowledge Survey) to physicians at the beginning and end of a Part 4 MOC project sponsored by a pediatric hospital's American Board of Medical Specialties' portfolio program during 2015. Participants worked in academic and community settings and in various accredited specialties. The main outcome was change in survey response on a 5-point Likert scale (1 = best) for 3 learning domains (QI engagement and attitude; QI method application, and improved patient care). RESULTS: Of 123 complete responses and a 97% response rate, mean baseline responses were positive or neutral (2.2, 2.3, 1.9, respectively). Responses improved in QI engagement and attitude (-0.15, z score = -2.78, P = .005), QI method application (-0.39, z score = -7.364, P < .005), and improved patient care (-0.11, z score = -1.728, P = .084). CONCLUSIONS: A Part 4 MOC physician survey provides valuable data to evaluate and improve the learning activity. In this children's hospital program, physicians view Part 4 favorably. Participation was associated with modest improvements in perceptions of QI engagement and attitude, application of QI methods, and patient care. Systematic evaluation of all Part 4 MOC projects and programs has the potential to improve the program nationally.