Abstract Body: Background: High-value practices (HVP) focus on optimal patient care with minimized costs and unnecessary interventions. At an academic comprehensive stroke center, echocardiography (echo) with bubble study was performed for all patients with ischemic stroke (IS) and transient ischemic attack (TIA) for patent foramen ovale (PFO) detection. This practice, especially in patients over age 65, could increase costs, resource use, and overtreatment, despite limited evidence for PFO closure in older adults where alternative stroke mechanisms are more likely.
Aim: Enhance HVP with targeted PFO screening by reduction of echo with bubble study in IS/TIA patients over 65 from 87.7% to 50% within one year.
Methods: In July 2023, vascular neurologists agreed on the limited utility of routine echo with bubble study in older adults. The Neuromedicine Intensive Care Unit revised standard practice, delaying echo orders until after rounds to assess necessity for bubble study on a case-by-case basis. Shorter length of stay (LOS) on inpatient units made delayed echo orders impractical; admission orders were modified to exclude bubble studies for patients over 65, except in cases of cryptogenic stroke. Changes were finalized in September 2023. Advanced practice providers and physicians monitored for adverse events (AEs) and process challenges. Hospital LOS was monitored as a balancing measure.
Results: Baseline (Jan-Jun 2023) rate of echo with bubble study in patients over 65 (n=212) was 87.7%. Following practice change, it decreased to 21.7% (n=544) from July 2023 through June 2024. Sustained reduction was observed after order revisions in September 2023 (Figure 1). No patients required repeat echo and none were reported to have an incomplete evaluation when seen by vascular neurology after discharge. While LOS did not appear to correlate with decrease in bubble studies, additional unrelated factors have impacted LOS. Initial challenges included confusion among echo schedulers, who applied the change universally regardless of order for bubble study. Early education resolved this issue.
Conclusions: We effectively reduced unnecessary echo with bubble study in older adults with IS/TIA without AEs over a year of monitoring. Continued use of bubble study in 10-15% of these patients reflects appropriate targeting for cryptogenic stroke. Future research should assess actual cost savings and relevance of echo with bubble study in younger patients with clearly defined stroke etiologies.