Study Limitations
While this meta-analysis provides robust evidence for the utility of AUC QI interventions and incorporates studies with a diverse group of providers, we believe that there is still not enough information to assess whether the results can be generalized to physicians across specialties and whether there are inter-specialty differences in the effectiveness of the interventions. Majority of the studies utilizing educational and feedback tools were targeted at three particular specialties: cardiology, internal medicine, and primary care physicians. However, in true clinical practice echocardiograms are ordered by physicians across all clinical specialties as well as by mid-level providers. Additionally, given that the majority of included studies using educational tools targeted a limited group of physicians, it is unclear how feasible it would be to implement similar QI interventions in larger, multi-provider settings.
One aspect that limits generalizability of this meta-analysis is the heterogeneity seen across studies. This is likely a result of differences in the inherent design and implementation of QI protocols across difference studies, thus the heterogeneity was expected. We addressed this via subgroup analysis by type of QI intervention and by duration of follow-up. This was effective in reducing heterogeneity in the decision-support tool subgroup. We further addressed this using a random effect model for analysis, which accounts for inherent differences in methodology and design across included studies.
Lastly, all studies included in this meta-analysis were performed at academic medical centers, making it difficult to generalize the results to the community setting where a significant portion of echocardiograms are ordered and performed.
The application of AUC-based QI interventions appears to be effective in reducing rarely appropriate echocardiography testing. This meta-analysis has shown that educational tools and decision support tools are effective QI interventions regardless of whether a feedback tool is incorporated. Further studies are needed to elucidate the effectiveness of different formats of feedback tools as well as the generalizability of AUC-based QI interventions in the community setting and across medical specialties.