Education, screening program nearly eradicates inappropriate catheterization

A one-month education and screening program at a rural tertiary medical center reduced inappropriate cardiac catheterization referrals by primary care physicians (PCPs) from 17 percent to zero percent.

James C. Blankenship, MD, and colleagues at Geisinger Medical Center in Danville, Pennsylvania, outlined their Appropriate Outpatient Catheterization (AOC) program in JACC: Cardiovascular Interventions:

• All PCPs referring cardiac catheterization patients were given a copy of the 2012 American College of Cardiology/Society for Cardiovascular Angiography and Interventions Appropriate Use Criteria (AUC) for cardiac catheterizations, in addition to a description of the new screening process.
• Specialists were educated about the AUC, which was posted in all cath labs, and encouraged to use a SCAI smartphone application to determine the appropriateness of catheterization.
• Advanced practitioners were required to determine the appropriateness of each case scheduled for catheterization.
• Patients were screened on the day of catheterization to confirm the appropriateness of the procedure.

Inappropriate referral was defined as an AUC score of 1 to 3. Before the intervention, 17.3 percent of 81 PCP referrals were deemed inappropriate. After the education and screening program was implemented, there were no inappropriate referrals among 52 cases.

A random sample of 381 referrals from cardiac specialists showed inappropriate referrals dropped from 3.3 percent to 2.2 percent after the program was implemented.

“Screening for appropriateness was easily integrated into the workflow of advanced practitioners and physicians, and required only several minutes per patient,” Blankenship and colleagues wrote. “The incidence of inappropriate CCs (cardiac catheterizations) referred by PCPs dropped significantly and was comparable to the incidence of inappropriate CCs referred by specialists. This program may serve as a template for other programs seeking to minimize inappropriate CCs.”

The authors noted they couldn’t determine which components of their program were most effective. They also pointed out “assessments of appropriateness are somewhat subjective and may have varied among raters.”