Application of appropriateness criteria in outpatient transthoracic echocardiography

The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and meta-analysis

BACKGROUND

The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion.

METHODS

We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing.

RESULTS

Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05).

CONCLUSION

QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.

Electrocardiogram-Based Machine Learning Emulator Model for Predicting Novel Echocardiography-Derived Phenogroups for Cardiac Risk-Stratification: A Prospective Multicenter Cohort Study

Purpose

Electrocardiography (ECG)-derived machine learning models can predict echocardiography (echo)-derived indices of systolic or diastolic function. However, systolic and diastolic dysfunction frequently coexists, which necessitates an integrated assessment for optimal risk-stratification. We explored an ECG-derived model that emulates an echo-derived model that combines multiple parameters for identifying patient phenogroups at risk for major adverse cardiac events (MACE).

Methods

In this substudy of a prospective, multicenter study, patients from 3 institutions (n=727) formed an internal cohort, and the fourth institution was reserved as an external test set (n=518). A previously validated patient similarity analysis model was used for labeling the patients as low-/high-risk phenogroups. These labels were utilized for training an ECG-derived deep neural network model to predict MACE risk per phenogroup. After 5-fold cross-validation training, the model was tested on the reserved external dataset.

Results

Our ECG-derived model showed robust classification of patients, with area under the receiver operating characteristic curve of 0.86 (95% CI: 0.79-0.91) and 0.84 (95% CI: 0.80-0.87), sensitivity of 80% and 76%, and specificity of 88% and 75% for the internal and external test sets, respectively. The ECG-derived model demonstrated an increased probability for MACE in high-risk vs low-risk patients (21% vs 3%; P<0.001), which was similar to the echo-trained model (21% vs 5%; P<0.001), suggesting comparable utility.

Conclusions

This novel ECG-derived machine learning model provides a cost-effective strategy for predicting patient subgroups in whom an integrated milieu of systolic and diastolic dysfunction is associated with a high risk of MACE.

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

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.

Unanticipated critical findings on echocardiography in septic patients

BACKGROUND

Echocardiography is increasingly performed among septic patients as a routine part of evaluation and management in the intensive care unit (ICU). The rate of unanticipated critical findings (e.g., severe left or right ventricular dysfunction or pericardial tamponade) on such echocardiograms is unknown. We evaluated a retrospective cohort of septic ICU patients in whom transthoracic echocardiography was performed as a routine part of sepsis management. In addition to identifying critical findings, we defined whether each critical finding was anticipated, and whether the clinical team responded to the critical finding. The primary outcome was rate of unanticipated critical findings, which we hypothesized would occur in fewer than 5% of patients. We also performed an exploratory analysis of the association between unanticipated critical finding and mortality, controlling for severity of illness.

RESULTS

We studied 393 patients. Unanticipated critical findings were identified in 5% (95% CI 3-7%) of patients (n = 20). Among the 20 patients with unanticipated critical findings, a response to the unanticipated critical finding was identified in 12 (60%) patients. An unanticipated critical finding was not significantly associated with 28-day mortality when controlling for admission APACHE II (p = 0.27).

CONCLUSIONS

Unanticipated critical findings on echocardiograms in septic ICU patients are uncommon. The potential therapeutic relevance of echocardiography to sepsis is more likely related to hemodynamic management than to traditional cardiac diagnoses. Research studies that employ blinded echocardiograms in septic patients may anticipate unblinding for critical findings approximately 1 in every 20 echocardiograms.

The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit

BACKGROUND

Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU.

METHODS

Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator.

RESULTS

Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101).

CONCLUSION

Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.

Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients

Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

Derivation of a Clinical Model to Predict Unchanged Inpatient Echocardiograms

BACKGROUND

Transthoracic echocardiography (TTE) is one of the most commonly ordered tests in healthcare. Repeat TTE, defined as a TTE done within 1 year of a prior TTE, represents 24% to 42% of all studies. The purpose of this study was to derive a clinical prediction model to predict unchanged repeat TTE, with the goal of defining a subset of studies that are unnecessary.

METHODS

Single-center retrospective cohort study of all hospitalized patients who had a repeat TTE between October 1, 2013, and September 30, 2014.

RESULTS

Two hundred eleven of 601 TTEs were repeat studies, of which 78 (37%) had major changes. Five variables were independent predictors of major new TTE changes, including history of intervening acute myocardial infarction, cardiothoracic surgery, major new electrocardiogram (ECG) changes, prior valve disease, and chronic kidney disease. Using the β-coefficient for each of these variables, we defined a clinical prediction model that we named the CAVES score. The acronym CAVES stands for chronic kidney disease, acute myocardial infarction, valvular disease, ECG changes, and surgery (cardiac). The prevalence of major TTE change for the full cohort was 35%. For the group with a CAVES score of -1, that probability was only 5.6%; for the group with a score of 0, the probability was 17.7%; and for the group with a score ≥1, the probability was 55.3%. The bootstrap corrected C statistic for the model was 0.78 (95% confidence interval, 0.72-0.85), indicating good discrimination.

CONCLUSIONS

Overall, the CAVES score had good discrimination and calibration. If further validated, it may be useful to predict repeat TTEs that are unlikely to have major changes.

Appropriateness of Outpatient Echocardiograms Ordered by Pediatric Cardiologists or Other Clinicians

OBJECTIVE

To assess the appropriateness and diagnostic yield of TTEs ordered by various pediatric providers according to the pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) before its release.

STUDY DESIGN

Clinic notes of patients aged ≤18 years who underwent initial outpatient TTE between April and September 2014 were reviewed to determine the AUC indication, and appropriateness was assigned based on the AUC document. Ordering physicians were categorized into cardiologists, primary care physicians (PCPs; including pediatricians and family practitioners [FPs]), and noncardiology subspecialists.

RESULTS

Of the 1921 TTEs ordered during the study period, 84.6% were by cardiologists, 9.2% by pediatricians, 3.4% by FPs, and 2.8% by noncardiology subspecialists. The appropriateness rate for cardiologists was higher than that for PCPs (86% vs 64%; P < .001) but not noncardiology subspecialist (86% vs 87%; P = .80). PCPs had a significantly higher proportion of studies that could not be classified compared with cardiologists (35% vs 5%; P < .001) and noncardiology subspecialists (35% vs 11%; P < .001), owing primarily to a lack of adequate clinical information. The likelihood of an abnormal finding was higher in TTEs ordered by a cardiologist vs those ordered by a noncardiologist (OR, 4.8; 95% CI, 2.1-10.9; P < .001).

CONCLUSIONS

Compared with PCPs, cardiologists ordered more TTEs, had the highest yield of abnormal findings, and had greater appropriateness of TTE orders. A large proportion of TTEs ordered by PCPs were unclassifiable owing to insufficient information. This study lays a framework for provider education and improvement in the TTE order intake process.

Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice

Pediatric appropriate use criteria (AUC) were recently published for initial outpatient transthoracic echocardiography (TTE). The purpose of this study was to determine the effect of AUC publication on TTE ordering patterns of pediatric cardiologists. Data were prospectively collected on patients who had initial outpatient TTE ordered before (phase I, April to September 2014) and 3 months after (phase II, January to April 2015) AUC document publication at 6 centers. Site investigators assessed each study's indication and assigned AUC appropriateness as "appropriate" (A), "may be appropriate" (M), "rarely appropriate" (R), or "unclassifiable." One hundred three physicians ordered 4,562 TTEs (2,655 phase I and 1,907 phase II). Overall, there was no statistically significant change in the proportion of A, M, or unclassifiable, but R decreased (12.0% to 9.6%, p = 0.01). There was significant variability among the centers in the percentage of studies for indications rated R (4.9% to 34.8%). There was no significant change in any of the appropriateness ratings at 4 centers, a decrease in R and an increase in A at 1 and a decrease in R and increase in unclassifiable at another. The first pediatric AUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. There was a significant variability in appropriateness of studies among centers. These data suggest that active educational interventions are required to substantially improve the appropriate use of pediatric TTE in the outpatient setting.

Development and validation of a screening tool for the identification of inappropriate transthoracic echocardiograms

OBJECTIVE

We sought whether simple clinical markers could be used in a questionnaire for recognition of inappropriate (or rarely appropriate, RA) tests at point-of-service. Most applications of appropriateness criteria (AC) for transthoracic echocardiogram (TTE) have been at the point of order, but a simple means of identifying RA tests in an audit process would be of value.

DESIGN, SETTING AND PARTICIPANTS

The study was performed in 2 major hospitals in Tasmania. 2 reviewers created a questionnaire based on 4 questions most commonly associated with RA (suspected endocarditis with no positive blood cultures or new murmur, lack of cardiovascular symptoms or no change in clinical status or cardiac examination, routine surveillance and previous TTE within a year) in a derivation cohort of 814 patients. This was prospectively applied to 499 TTEs to calculate sensitivity and specificity for prediction of RA, and validated in the external group (n=880).

RESULTS

Of 499 prospective TTEs, the questionnaire selected 18% requests as being potentially RA. As 7.4% were actually RA (κ 89%), the sensitivity and specificity of the questionnaire were 84% and 87%, respectively. In the external validation cohort, the model found 11% requests needed to be screened for appropriateness with a sensitivity and specificity of 80% and 95%.

CONCLUSIONS

A questionnaire based on 4 questions detects a high proportion of RA TTE, and could be used for audit.

Impact of a structured referral algorithm on the ability to monitor adherence to appropriate use criteria for transthoracic echocardiography

BACKGROUND

Many free-form-text referral requisitions for transthoracic echocardiography (TTE) provide insufficient information to adequately evaluate their adherence to Appropriate Use Criteria (AUC). We developed a structured referral requisition algorithm based on requisition deficiencies identified retrospectively in a derivation cohort of 1303 TTE referrals and evaluated the performance of the algorithm in a consecutive series of cardiology outpatient referrals.

METHODS

The validation cohort comprised 286 consecutive TTE outpatient cardiology referrals over a 2-week period. The relevant AUC indication was identified from information extracted from the free-form-text requisition. The structured referral algorithm was applied prospectively to the same cohort using information from the free-form-text requisition, electronic medical record and ordering clinicians. Referrals were classified as appropriate, uncertain, non-adherent (inappropriate) or unclassifiable based on the American College of Cardiology Foundation 2011 AUC.

RESULTS

Only 28.7 % of free-form-text requisitions provided adequate information to identify the relevant AUC indication, as compared to 94.4 % of referrals using the structured referral algorithm (p < 0.001). The structured algorithm improved identification in the AUC categories of general evaluation of cardiac structure/function (100 % vs. 43.0 %, p < 0.001); valvular function (100 % vs. 23.0 %, p < 0.001); hypertension, heart failure or cardiomyopathy (100 % vs. 20.3 %, p < 0.001); and adult congenital heart disease (100 % vs. 0 %, p < 0.001). By applying the algorithm, the number of identifiable non-adherent studies increased from 2.6 to 10.4 % (p <0.001).

CONCLUSIONS

Use of a structured TTE referral algorithm, as opposed to a free-form-text requisition, allowed the vast majority of referrals to be monitored for AUC adherence and facilitated the identification of potentially inappropriate referrals.

Design and methods of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantlY) study: An investigator-blinded randomized controlled trial of education and feedback intervention to reduce inappropriate echocardiograms

BACKGROUND

Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings.

AIMS

The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment.

METHODS

In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice.

CONCLUSIONS

The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101).

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Temporal changes in appropriateness of cardiac imaging

BACKGROUND

Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined.

OBJECTIVES

This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests.

METHODS

Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression.

RESULTS

New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography.

CONCLUSIONS

Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.

Limitations of free-form-text diagnostic requisitions as a tool for evaluating adherence to appropriate use criteria for transthoracic echocardiography

BACKGROUND

Monitoring the adherence to Appropriateness Use Criteria (AUC) has been identified as an important component for the accreditation of echocardiography laboratories. Referral requisitions are a logical tool to rapidly determine the appropriateness of transthoracic echocardiography (TTE) referrals, however data is lacking. We investigated whether standard free-form-text TTE referral requisitions can be used to evaluate AUC adherence.

METHODS

Consecutive TTE referral requisitions to the University of Ottawa Heart Institute echocardiography laboratory were reviewed over a four-week period. Indication on the requisition was matched with the relevant indication on the 2011 American College of Cardiology Foundation (ACCF) AUC. Requisitions that did not provide sufficient information to identify the relevant AUC indication were identified as inadequate. For inadequate requisitions, reason for the referral was clarified through medical records and referring physicians.

RESULTS

Of the 1303 requisitions, 26.2% did not provide adequate information to determine adherence to AUC, despite a non-adherence (inappropriate) rate of only 6.1% in the referral population. Indication for referral, physician specialty, outpatient status, and prior echocardiogram were independent predictors of inadequate requisitions (p < 0.001, respectively). The most common reasons for inadequate requisitions were a failure to report: 1) change in clinical status, 2) date of a prior echocardiogram, and 3) type and/or severity of a valve lesion. Inclusion of this information would have decreased the inadequacy rate by 56%.

CONCLUSION

In a large, academic echocardiography laboratory, over one quarter of free-form-text TTE requisitions are inadequate to evaluate AUC adherence. Structured requisition formats requiring AUC-relevant information are needed to facilitate the practical application of AUC in the echocardiography laboratory.

Adherence to the 2010 American College of Cardiology Foundation Appropriate Use Criteria for Cardiac Computed Tomography: Quality Analysis at a Tertiary Referral Center

BACKGROUND

In November 2010, the American College of Cardiology Foundation published revised appropriateness criteria (AC) for cardiac computed tomography (CT). We evaluated adherence to these criteria by providers of different subspecialties at a tertiary referral center.

METHODS

Reports of 383 consecutive patients who underwent clinically indicated cardiac CT from December 1, 2010, to July 31, 2011, were reviewed by physicians with appropriate training in cardiac CT. Scans were classified as appropriate, inappropriate, or uncertain based on the revised 2010 AC. Studies that did not fall under any of the specified indications were labeled as unclassified. Adherence to the AC was also analyzed as a function of provider type. Research scans were excluded from this analysis.

RESULTS

Three hundred eight exams (80%) were classified as appropriate; 26 (7%), as inappropriate; 30 (8%), as uncertain; and 19 (5%), as unclassified. Of the 19 (5%) unclassified cardiac CT exams, the most common indication was for evaluation of suspected aortic dissection. Three hundred five exams (80%) were referred by cardiologists; 73 (19%), by internists; and 5 (1%), by neurologists. Of the 305 cardiology-referred studies, 221 (73%) were ordered by general cardiologists; 28 (9%), by interventional cardiologists; and 56 (19%), by electrophysiologists. There was no significant difference in adherence to the criteria between provider specialties or between cardiology subspecialties (P > 0.05).

CONCLUSIONS

high across provider specialties.

How I do it: judging appropriateness for TTE and TEE

The increasing cost of healthcare is a widespread international problem to which the cost of imaging has been an important contributor. Some imaging tests are ordered inappropriately and contribute to wasted use of resources. Appropriate use criteria have been developed in the USA in order to guide test selection, but there are a number of problems, including the evidence base for these criteria and the steps that can be taken to change physician practice. A restrictive approach to test ordering is difficult to fit to the nuances of clinical presentation and may compromise patient care. We propose an alternative approach to physician guidance based on the most common markers of inappropriate testing.

Comparison of the 2006 and 2010 cardiac CT appropriateness criteria in a real-world setting

BACKGROUND

Coronary CT angiography (CCTA) is a relatively new technique whose role has yet to be fully defined. The initial appropriateness criteria (AC) guidelines published in 2006 have already been revised. There is paucity of data on the effect of the AC on the use of CCTA at academic centers and none for the private sector.

METHODS

All CCTA studies ordered at one institution (a large community hospital with internal medicine and cardiovascular training programs) from 2006 to 2008 were retrospectively evaluated, and the ordering indications were categorized per the published AC for both 2006 and 2010.

RESULTS

There were 384 studies, of which 243 were included in this study. The majority of the studies were ordered for chest pain (67.1% of patients). A significant proportion of studies (43.2%) were classified as inappropriate on the basis of the 2006 published criteria. Uncertain indications made up 39.1%, and appropriate indications were a minority. There was a significant regrading of appropriateness using the 2010 guidelines. Inappropriate testing remained similar at 48.1%, but uncertain cases decreased to only 2.8%, while appropriateness increased to 49.0% (P = .0001 for trend).

CONCLUSIONS

The updated 2010 AC guidelines for CCTA resulted in a significant reclassification of the indications for ordering CCTA from the previous 2006 guidelines. This shift in the AC reflects increased familiarity and confidence with this new technology across the imaging community. A large proportion of CCTA studies were ordered for inappropriate indications using both sets of criteria. Further research and enhanced education are needed to disseminate the appropriate role of CCTA in cardiovascular imaging.

Evaluation of appropriate use of transthoracic echocardiography in 1,820 consecutive patients using the 2011 revised appropriate use criteria for echocardiography

Revised Appropriate Use Criteria (AUC) for Echocardiography were published in 2011 and classify potential procedure indications as appropriate (score of 7 to 9), uncertain (score of 4 to 6), or inappropriate (score of 1 to 3). The appropriate utilization rate of transthoracic echocardiography in clinical practice using the revised AUC is unknown. The aim of the present study was to determine the appropriate utilization rate of echocardiography in a large number of consecutive studies in clinical practice and to determine the number of "unclassifiable" studies using the revised and expanded AUC. The clinical indication for transthoracic echocardiography (TTE) was determined on the basis of a detailed review of preprocedural clinical documentation. These clinical indications were further classified (when possible) into 1 of the 98 indications described in the 2011 AUC for echocardiography. From December 2010 to January 2011, 1,825 patients (mean age 63.2 years) underwent TTE for clinical reasons. Of the final study group of 1,820 patients, TTE was appropriate in 82%, inappropriate in 12.3%, and uncertain in 5.3%, and 0.4% studies were unclassifiable. The evaluation of symptoms potentially due to a cardiac etiology was the most common appropriate indication for TTE (27.5%). The most common inappropriate indication was routine surveillance (<1 year) of heart failure without a change in clinical status (2.5%). In conclusion, most TTE studies were appropriately ordered, and only a very small number of studies were unclassifiable.

Appropriateness use criteria for transthoracic echocardiography: relationship with radiology benefit managers preauthorization determination and comparison of the new (2010) criteria to the original (2007) criteria

BACKGROUND

In response to growth in cardiac imaging, medical societies have published appropriateness use criteria (AUC) and payers have introduced preauthorization mandates, largely through radiology benefits managers (RBM). The correlation of algorithms used to determine preauthorization with the AUC is unknown. In addition, studies applying the 2007 AUC for transthoracic echocardiography revealed that many echocardiograms could not be classified. We sought to examine the impact of the revised 2010 AUC on appropriateness ratings of transthoracic echocardiograms previously classified by the 2007 AUC and the relationship of preauthorization determination to AUC rating.

METHODS

We reclassified indications for transthoracic echocardiography as appropriate, inappropriate, uncertain, or unclassifiable using the 2010 AUC in the same 625 patients previously reported using 2007 AUC. We also evaluated the relationship between preauthorization status by 2 RBM precertification algorithms and appropriateness rating by 2007 AUC.

RESULTS

The appropriateness classification of 148 (24%) transthoracic echocardiograms was changed by the updated AUC (P < .001). The number of unclassifiable echocardiograms was markedly reduced from 99 (16%) to 8 (1%), and more echocardiograms were classified as inappropriate (95 [15%] vs 45 [7%]) or uncertain (43 [7%] vs 0 [0%]). Limited correlation between the 2007 AUC rating and RBM preauthorization determinations was noted, with only moderate agreement with RBM no. 1 (90%, κ = 0.480, P < .001) and poor agreement with RBM no. 2 (72%, κ = 0.177, P < .001).

CONCLUSION

The updated AUC (2010) provide enhanced clinical value compared with 2007 AUC. There is limited agreement between RBM preauthorization determination and 2007 AUC rating.

Trends in outpatient transthoracic echocardiography: impact of appropriateness criteria publication

BACKGROUND

The impact of the 2007 American College of Cardiology Foundation Transthoracic Echocardiography Appropriateness Criteria on trends in appropriateness is unknown. Therefore, we sought to identify the appropriateness of outpatient transthoracic echocardiography pre- and postpublication of this document.

METHODS

The 2007 Appropriateness Criteria were used to classify outpatient echocardiographic studies at an academic medical center during October 2000 and October 2008. The patient's electronic medical record was used to identify echocardiographic indication and appropriateness.

RESULTS

From October 2000 to October 2008, there was an 85% increase in outpatient echocardiographic volume. Using the Appropriateness Criteria, there was no significant change in inappropriate referrals (13% and 15%, P=.58). Sixty-five studies (12%) were referred for indications "not addressed" by the document, with an increase (7% to 15%, P=.012) from 2000 to 2008. In a second analysis, incorporating the 2008 Valve Guidelines, an increase was demonstrated in the total number of studies that could be classified, but there was no significant change in the proportion of inappropriate referrals (P=.50). There remained a significant increase (3% to 10%, P=.009) in the proportion of indications "not addressed" by either guideline.

CONCLUSION

From October 2000 to October 2008, we experienced a near doubling of outpatient echocardiographic volume, with no significant change in the percent of inappropriate referrals despite interim publication of the Appropriateness Criteria document. In addition, there was an increase in echocardiographic referrals for "not addressed" indications. Future efforts are needed both to refine the Appropriateness Criteria to include unaddressed indications and to promote its effective implementation.

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians

The American College of Cardiology Foundation (ACCF), in partnership with the American Society of Echocardiography (ASE) and along with key specialty and subspecialty societies, conducted a review of common clinical scenarios where echocardiography is frequently considered. This document combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 (1) and the original stress echocardiography appropriateness criteria published in 2008 (2). This revision reflects new clinical data, reflects changes in test utilization patterns,and clarifies echocardiography use where omissions or lack of clarity existed in the original criteria.The indications (clinical scenarios)were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC).The 202 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9,to designate appropriate use(median 7 to 9), uncertain use(median 4 to 6), and inappropriate use (median 1 to 3). Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general,the use of echocardiography for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management were rated appropriate. Routine testing when there was no change in clinical status or when results of testing were unlikely to modify management were more likely to be inappropriate than appropriate/uncertain.The AUC for echocardiography have the potential to impact physician decision making,healthcare delivery, and reimbursement policy. Furthermore,recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Use of a web-based application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Use Criteria for Transthoracic Echocardiography: a pilot study

BACKGROUND

Clinical application of the American College of Cardiology Foundation Appropriate Use Criteria (AUC) represents a potentially feasible alternative to third-party pre-certification for imaging procedures and will soon be required as part of the accreditation process for imaging laboratories. Electronic tools that rapidly apply the AUC are needed in clinical practice. We developed and tested a web-based application of the AUC to track appropriateness of transthoracic echocardiography (TTE).

METHODS

Indications for outpatient TTE studies performed in a university hospital echocardiography laboratory were assessed prospectively at the point of service using a prototype web-based AUC application (Echo AUC App). The Echo AUC App was developed on the basis of our own prior published data regarding indication frequency to minimize time and screens required for completion. Echo AUC App-determined indications were compared with blinded investigator-determined indications based on review of relevant medical records. Echo AUC App characteristics, including Echo AUC App entry time, were recorded.

RESULTS

Of the 258 studies enrolled, Echo AUC App-determined TTE indications were Appropriate (A) in 77% (n = 198), Inappropriate (I) in 9% (n = 23), and Not Classified (NC) by the AUC in 14% (n = 37). Agreement between Echo AUC App- and investigator-determined classifications was excellent (94%, kappa statistic 0.83). Mean Echo AUC App study entry time was 55 seconds (range 25-280 seconds).

CONCLUSION

The use of an electronic application allows rapid and accurate implementation of the AUC for TTE at the point of service. Such an application could be installed in echocardiography laboratories to track appropriateness in accordance with soon-to-be-implemented accreditation requirements. Further study of this Echo AUC App at the point of order may provide an alternative to third-party pre-certification procedures.

Appropriate use of transthoracic echocardiography

The appropriateness criteria for echocardiography were published in 2007 and classified potential procedural indications as appropriate, uncertain, or inappropriate. The appropriate use rates for outpatient transthoracic echocardiography (TTE) by cardiologists have not been well defined. The objective of the present study was to prospectively determine the appropriate use rate of outpatient TTE in a large private practice group of >40 cardiologists (Cardiovascular Consultants, PA, Kansas City, Missouri). For each transthoracic echocardiographic study, we classified the stated reason for the examination into one of the 59 indications specified in the 2007 Appropriateness Criteria for Echocardiography publication. During the study period, 772 transthoracic echocardiographic studies were performed. Adequate information was available to classify 716 (92.7%) of these studies. The transthoracic echocardiographic studies were appropriately ordered for 533 patients (74%). Symptoms of potential cardiac origin (eg, dyspnea) was the most common reason for TTE (n = 156, 21.8%). The most common inappropriate use was routine repeat evaluation of patients with heart failure and no change in clinical status (n = 74, 10.3%). In conclusion, the appropriateness criteria for echocardiography were easily applied to real-world patients. Most patients in our series had undergone TTE for an appropriate indication.