An initiative to promote value‐based stress test selection in primary care and cardiology clinics: A mixed methods evaluation

Objectives Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower‐cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value‐based, guideline‐concordant ordering practices in primary care (PC) and cardiology clinics. Methods Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019–February 2020); Period 1 with reduced stress ECG report turnaround time + PC‐targeted education (began June 2020); and Period 2 with the addition of electronic health record‐based alternative alert (AA) providing point‐of‐care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. Results Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value‐based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p