Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare

Cultivating Competency in Cardiac Sonography: Aligning Entrustable Professional Activities With Industry Expectations

BACKGROUND & AIM

Echocardiography education involves the teaching and assessment of multiple competencies to ensure work-ready graduates. To connect these competency standards to professional practice, it is important that the industry expectation around specific entrustable professional activities (EPAs) is determined. In Australia, echocardiography examinations are eligible for Medicare reimbursement when performed by sonographers listed on the Australian Sonographers Accreditation Registry (ASAR), either as an Accredited Medical Sonographer or as an Accredited Student Sonographer. A key criterion for acceptance onto the registry is the completion of, or active enrolment in, an accredited cardiac sonography course. Eligible courses apply for accreditation and are assessed by ASAR against their Standards for Accreditation of Sonographer Courses. This study sought to investigate the existing cardiac EPAs and provide insights into the industry's expectations for graduate cardiac sonographers in Australia.

METHODS

Using an anonymous online survey tool, an invitation to participate was circulated via professional sonography groups and social media platforms. Accredited Medical Sonographers, Accredited Student Sonographers or interested stakeholders (academic, employer, medical specialist) working in Australia or New Zealand were invited to complete the survey. Survey questions were structured around the existing EPAs and knowledge items described in published sonography competency documents. Participants were asked if each individual EPA should be considered appropriate at the threshold of graduation, or at a higher level following a period of working in the profession.

RESULTS

There were 211 cardiac sonographers who completed the survey. The majority of respondents (148 of 211, 72.2%) indicated that the current EPAs should be updated. At 80% agreement, the following EPAs were considered essential for the graduate: left ventricular structure and function, right ventricular structure and function, atrial size, valvular disease, systemic hypertension, cardiomyopathies, diseases of the aorta, coronary artery disease, pulmonic hypertension, and basic congenital heart disease. This list is more extensive than the current ASAR-endorsed EPAs, and the findings in this research will guide the revision of current ASAR-endorsed EPAs for graduate-level cardiac sonography.

CONCLUSIONS

The results of this study show Accredited Medical Sonographers completing a cardiac sonography course in Australia should be entrusted to perform a wide range of examinations however, greater alignment between educational providers, ASAR and industry is still required.

Circulating osteoprotegerin as a cardiac biomarker for left ventricular diastolic dysfunction in patients with pre-dialysis chronic kidney disease: the KNOW-CKD study

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a major cause of mortality in patients with chronic kidney disease (CKD), and diagnosis is challenging. Moreover, no specific biomarker for HFpEF has been validated in patients with CKD. The present study aimed to investigate the association between serum osteoprotegerin (OPG) levels and the risk of left ventricular diastolic dysfunction (LVDD), a surrogate of HFpEF, in patients with pre-dialysis CKD.

METHODS

A total of 2039 patients with CKD at stage 1 to pre-dialysis 5 were categorized into quartiles (Q1 to Q4) by serum OPG levels, and were cross-sectionally analyzed. The study outcome was LVDD, which was operationally defined as the ratio of early transmitral blood flow velocity to early diastolic velocity of the mitral annulus (E/e') > 14.

RESULTS

In the analysis of baseline characteristics, higher serum OPG levels were clearly related to the risk factors of HFpEF. A scatter plot analysis revealed a moderate correlation between serum OPG levels and E/e' (R = 0.351, P < 0.001). Logistic regression analysis demonstrated that the risk of LVDD in Q3 (adjusted odds ratio 2.576, 95% confidence interval 1.279 to 5.188) and Q4 (adjusted odds ratio 3.536, 95% confidence interval 1.657 to 7.544) was significantly higher than that in Q1.

CONCLUSIONS

Elevated serum OPG levels are associated with the risk of LVDD in patients with pre-dialysis CKD. The measurement of serum OPG levels may help the diagnosis of LVDD, which is an important echocardiographic feature of HFpEF.

Clinical Validation of an Artificial Intelligence-Based Tool for Automatic Estimation of Left Ventricular Ejection Fraction and Strain in Echocardiography: Protocol for a Two-Phase Prospective Cohort Study

BACKGROUND

Echocardiography (ECHO) is a type of ultrasonographic procedure for examining the cardiac function and morphology, with functional parameters of the left ventricle (LV), such as the ejection fraction (EF) and global longitudinal strain (GLS), being important indicators. Estimation of LV-EF and LV-GLS is performed either manually or semiautomatically by cardiologists and requires a nonnegligible amount of time, while estimation accuracy depends on scan quality and the clinician's experience in ECHO, leading to considerable measurement variability.

OBJECTIVE

The aim of this study is to externally validate the clinical performance of a trained artificial intelligence (AI)-based tool that automatically estimates LV-EF and LV-GLS from transthoracic ECHO scans and to produce preliminary evidence regarding its utility.

METHODS

This is a prospective cohort study conducted in 2 phases. ECHO scans will be collected from 120 participants referred for ECHO examination based on routine clinical practice in the Hippokration General Hospital, Thessaloniki, Greece. During the first phase, 60 scans will be processed by 15 cardiologists of different experience levels and the AI-based tool to determine whether the latter is noninferior in LV-EF and LV-GLS estimation accuracy (primary outcomes) compared to cardiologists. Secondary outcomes include the time required for estimation and Bland-Altman plots and intraclass correlation coefficients to assess measurement reliability for both the AI and cardiologists. In the second phase, the rest of the scans will be examined by the same cardiologists with and without the AI-based tool to primarily evaluate whether the combination of the cardiologist and the tool is superior in terms of correctness of LV function diagnosis (normal or abnormal) to the cardiologist's routine examination practice, accounting for the cardiologist's level of ECHO experience. Secondary outcomes include time to diagnosis and the system usability scale score. Reference LV-EF and LV-GLS measurements and LV function diagnoses will be provided by a panel of 3 expert cardiologists.

RESULTS

Recruitment started in September 2022, and data collection is ongoing. The results of the first phase are expected to be available by summer 2023, while the study will conclude in May 2024, with the end of the second phase.

CONCLUSIONS

This study will provide external evidence regarding the clinical performance and utility of the AI-based tool based on prospectively collected ECHO scans in the routine clinical setting, thus reflecting real-world clinical scenarios. The study protocol may be useful to investigators conducting similar research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44650.

Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool

Study objective

Reduce inappropriate transthoracic echocardiograms (TTEs) using a series of Plan-Do-Study-Act (PDSA) quality improvement cycles.

Design

Three PDSA cycles were designed with the first integrating a previously published decision support tool (DST) into the electronic TTE order, the second tailoring the DST to reflect the most common inappropriately ordered TTEs at our institution, and the third integrating direct clinician education.

Setting

Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA.

Participants

Consecutive patients were studied using the database of all TTEs performed at our institution without regard for specific patient characteristics.

Interventions

Three PDSA Cycles as described above.

Main outcome measure

Reduction in inappropriate TTEs at our institution.

Results

After implementing our DST during the first cycle, no difference in inappropriate TTEs was observed (relative risk [RR] 0.71, p = 0.12, 95 % confidence interval [CI] 0.46-1.09). After the second cycle, we observed a reduction in the proportion of inappropriate TTEs (RR = 0.69, p = 0.014, 95 % CI 0.5-0.94), however two of the four inappropriate TTEs targeted by the DST increased. Feedback gathered from clinicians in the third cycle showed significant knowledge gaps regarding appropriate use criteria for TTE.

Conclusions

At our facility, implementation of a DST failed to substantially reduce inappropriate TTEs, even when adapted to facility-specific ordering patterns. Gaps in clinician knowledge about TTEs may have contributed to the inefficacy of our DST.

Evaluation of Appropriate Use of Preoperative Echocardiography before Major Abdominal Surgery: A Retrospective Cohort Study

BACKGROUND

Preoperative resting echocardiography is often performed before noncardiac surgery, but indications for preoperative resting echocardiography are limited. This study aimed to investigate appropriateness of preoperative resting echocardiography using the Appropriate Use Criteria for Echocardiography, which encompass indications from the guidelines on perioperative cardiovascular evaluation and management and nonperioperative indications independent of the perioperative period. The authors hypothesized that patients are frequently tested without an appropriate indication.

METHODS

Records of patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent a major abdominal surgery from 2005 to 2017 were included. These databases contain de-identified records of health services for more than 250 million patients with primary or Medicare supplemental health insurance coverage through employer-based fee-for-service, point-of-service, or capitated plans. Patients were classified based on the presence of an outpatient claim for resting transthoracic echocardiography within 60 days of surgery. Appropriateness was determined via International Classification of Diseases, Ninth Revision-Clinical Modification, and International Classification of Diseases, Tenth Revision-Clinical Modification principal and secondary diagnosis codes associated with the claims, and classified as "appropriate," "rarely appropriate," or "unclassifiable" using the Appropriate Use Criteria for Echocardiography.

RESULTS

Among 230,535 patients in the authors' cohort, preoperative resting transthoracic echocardiography was performed in 6.0% (13,936) of patients. There were 12,638 (91%) studies classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Among the classifiable studies, 8,959 (71%) were deemed "appropriate," while 3,679 (29%) were deemed "rarely appropriate." Surveillance of chronic ischemic heart disease and uncomplicated hypertension accounted for 43% (1,588 of 3,679) of "rarely appropriate" echocardiograms.

CONCLUSIONS

More than one in four preoperative resting echocardiograms were considered "rarely appropriate" according to the Appropriate Use Criteria for Echocardiography. A narrow set of patient characteristics accounts for a large proportion of "rarely appropriate" preoperative resting echocardiograms.

EDITOR’S PERSPECTIVE

Protective Effects of Dexazoxane on Rat Ferroptosis in Doxorubicin-Induced Cardiomyopathy Through Regulating HMGB1

Dexrazoxane (DXZ) reduces cytotoxicity caused by Doxorubicin (DOX). However, the mechanism of DXZ in ferroptosis and cardiomyopathy remains unclear. This research, therefore, explores the role and mechanism of DXZ in DOX-induced ferroptosis and cardiomyopathy in rats. Kaplan–Meier survival analysis was performed in rats treated by DOX in combination with ferroptosis inhibitor (FER-1) or other cell death–associated inhibitors. The ferroptosis, cardiotoxicity, and expression of high mobility group box 1 (HMGB1) in rats treated by DOX in combination with FER-1 or with DXZ were determined by hematoxylin and eosin staining, echocardiographic analysis, and quantitative real-time PCR. The ferroptosis in DOX-treated rats that received HMGB1 knockdown or overexpression was further detected using molecular experiments. Finally, the viability, level of malondialdehyde (MDA), and expressions of ferroptosis-related markers (PTGS2, GPX4, and FTH1) of rat cardiomyocyte H9c2 exposed to DOX combined with FER-1, zVAD (an apoptosis inhibitor), DXZ, or not were detected by performing molecular experiments. FER-1 increased the survival of the rats induced by DOX. The DOX-induced ferroptosis and cardiotoxicity could be reversed by FER-1 or DXZ. HMGB1 was induced by DOX but was inhibited by DXZ or FER-1. Overexpression of HMGB1 promoted the ferroptosis and cardiotoxicity induced by DOX in the rats although silencing of HMGB1 showed opposite effects. The data indicate that DOX suppressed the viability and increased the MDA level in H9c2 cells in a dose-dependent manner. Moreover, DOX-induced increase of PTGS2 and decrease of GPX4 and FTH1 in H9c2 cells was reversed by DXZ or FER-1. Therefore, DXZ has protective effects on ferroptosis and cardiomyopathy in rats through regulating HMGB1.

The Rate of Appropriate Adult Transthoracic Echocardiogram at King Abdulaziz University Hospital Based on Appropriate Use Criteria of 2011, 2017, and 2019

Background: Transthoracic echocardiography (TTE) is a basic method for cardiovascular disease diagnosis and treatment. Studies done to assess the appropriate use of TTE in the Kingdom of Saudi Arabia (KSA) are scarce.

Objectives: To assess the pattern of ordering TTE in King Abdulaziz University Hospital (KAUH) and the appropriateness of its ordering.

Methods: A retrospective study was done from October to November 2018 at KAUH, Echo lab, Jeddah City, KSA. Patients, more than 18 years who had TTE at KAUH were included.

Results: The criteria used were the 2019 criteria for most patients and the orders were appropriate for 77.9% of the 954 patients. Orders were significantly inappropriate for patients who had older age, and the number of indications were significantly higher for those whose orders were - "maybe appropriate" (M). The anesthesia department for outpatients and the surgical department for inpatients ordered a significantly high number of inappropriate requests. Inpatients had a significantly higher percentage of "appropriate" (A) orders, and a significant positive correlation was present between patients’ age and number of indications.

Conclusion: There is a need to maximize compliance with AUCs and its effect on clinical results should be evaluated.

Frequency and Outcomes of Preoperative Stress Testing in Total Hip and Knee Arthroplasty from 2004 to 2017

Importance

Cardiac stress testing is often performed prior to noncardiac surgery, although trends in use of preoperative stress testing and the effect of testing on cardiovascular outcomes are currently unknown.

Objective

To describe temporal trends and outcomes of preoperative cardiac stress testing from 2004 to 2017.

Design, Setting, and Participants

Cross-sectional study of patients undergoing elective total hip or total knee arthroplasty from 2004 to 2017. Trend analysis was conducted using Joinpoint and generalized estimating equation regression. The study searched IBM MarketScan Research Databases inpatient and outpatient health care claims for private insurers including supplemental Medicare coverage and included patients with a claim indicating an elective total hip or total knee arthroplasty from January 1, 2004, to December 31, 2017.

Exposures

Elective total hip or knee arthroplasty.

Main Outcomes and Measures

Trend in yearly frequency of preoperative cardiac stress testing.

Results

The study cohort consisted of 801 396 elective total hip (27.9%; n = 246 168 of 801 396) and total knee (72.1%; 555 228 of 801 396) arthroplasty procedures, with a median age of 62 years (interquartile range, 57-70 years) and 58.1% women (n = 465 545 of 801 396). The overall rate of stress testing during the study period was 10.4% (n = 83 307 of 801 396). The rate of stress tests increased 0.65% (95% CI, 0.09-1.21; P = .03) annually from quarter (Q) 1 of 2004 until Q2 of 2006. A joinpoint was identified at Q3 of 2006 (95% CI, 2005 Q4 to 2007 Q4) when preoperative stress test use decreased by -0.71% (95% CI, -0.79% to 0.63%; P < .001) annually. A second joinpoint was identified at the Q4 of 2013 (95% CI, 2011 Q3 to 2015 Q3), when the decline in stress testing rates slowed to -0.40% (95% CI, -0.57% to -0.24%; P < .001) annually. The overall rate of myocardial infarction and cardiac arrest was 0.24% (n = 1677 of 686 067). Rates of myocardial infraction and cardiac arrest were not different in patients with at least 1 Revised Cardiac Risk Index condition who received a preoperative stress test and those who did not (0.60%; n = 221 of 36 554 vs 0.57%; n = 694 of 122 466; P = .51).

Conclusions and Relevance

The frequency of preoperative stress testing declined annually from 2006 through 2017. Among patients with at least 1 Revised Cardiac Risk Index condition, no difference was observed in cardiovascular outcomes between patients who did and did not undergo preoperative testing.

Role of Doppler echocardiography for assessing right ventricular cardiac output in patients with atrial septal defect

BACKGROUND

Although Doppler echocardiography is routinely used to assess left ventricle cardiac output, there are limited data about the feasibility of Doppler echocardiography for right ventricular (RV) cardiac output assessment in patients with left-to-right shunt. The purpose of the study was to determine the correlation between Doppler-derived and Fick-derived RV cardiac index (CI), and the interobserver correlation in Doppler-derived RV CI assessment.

METHODS

Retrospective study of patients (age ≥18 years) with unrepaired atrial septal defect who underwent cardiac catheterization and echocardiography (within 3 days), 2004-2017. RV CI was calculated using the hydraulic orifice formula: [.785 × (right ventricle outflow tract diameter)²  × right ventricular outflow tract (RVOT) time velocity integral × heart rate]/body surface area.

RESULTS

A total of 128 patients (age 52 ± 17 years; female 88 [69%]) met the inclusion criteria. There was a modest correlation between Doppler-derived and Fick-derived RV CI (r = .57, P < .001), and the mean difference between Doppler-derived and Fick-derived RV CI was -.3 (95% confidence interval of agreement, -.8 to +.9) L/min/m² . There was also a modest correlation between Doppler-derived RV CI from observer #1 and observer #2 (r = .62, P < .001), and the mean difference between Doppler-derived RV CI from observer #1 and observer #2 was -.2 (95% confidence interval of agreement, -.9 to +.6).

CONCLUSIONS

The current study demonstrated a modest correlation between Doppler-derived and Fick-derived RV cardiac output, and a modest interobserver correlation in Doppler-derived RV cardiac output assessment. Further studies are required to validate these results and to explore other potential applications such as in patients with chronic pulmonary regurgitation.

Assessment of barriers and facilitators in the implementation of appropriate use criteria for elective percutaneous coronary interventions: a qualitative study

Background

The use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness.

Methods

All hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC.

Results

Specific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography.

Conclusions

The identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.

An Automated System for Categorizing Transthoracic Echocardiography Indications According to the Echocardiography Appropriate Use Criteria

The Echocardiography Appropriate Use Criteria (EAUC) are a set of indications for transthoracic echocardiography (TTE) developed to guide physician decision making around ordering of TTE. In this study, an automated rule-based method for processing "indications" listed within TTE reports and classification into one of the major EAUC categories was developed and validated against a clinician-annotated reference standard. The system performed at a comparable level to trained physicians allowing for the automated classification of more than 30,000 TTE indications from a public database in less than ten minutes. The most common indication for TTE was Valvular assessment closely followed by General. Hypertension/Heart Failure/Cardiomyopathy, Acute, and Cardiac Structure assessment each contributed more than ten percent within this patient population. These results suggest potential for automated approaches for tracking appropriate use of TTE, as well as guide the development of systems for prospectively identifying when TTE use is recommended.