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Simos P, Scott I. Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope. Postgrad Med J 2022; 99:postgradmedj-2021-141416. [PMID: 35169024 DOI: 10.1136/postgradmedj-2021-141416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/22/2022] [Indexed: 01/03/2023]
Abstract
STUDY PURPOSE Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary. STUDY DESIGN We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients. RESULTS Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028). CONCLUSION In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.
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Affiliation(s)
- Peter Simos
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia .,School of Clinical Medicine, University of Queensland Faculty of Health and Behavioural Sciences, Herston, Queensland, Australia
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2
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Stone JR, Lee L, Ward JP, Ward RP. High Prevalence of Clinically Important Echocardiographic Abnormalities in Patients with a Normal Electrocardiogram Referred for Transthoracic Echocardiography. J Am Soc Echocardiogr 2018; 31:926-932. [DOI: 10.1016/j.echo.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Indexed: 10/14/2022]
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Singh A, Ward RP. Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare. Curr Cardiol Rep 2017; 18:93. [PMID: 27553788 DOI: 10.1007/s11886-016-0758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.
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Affiliation(s)
- Amita Singh
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA.
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4
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Sachdeva R, Kelleman MS, McCracken CE, Campbell RM, Lai WW, Lopez L, Stern KW, Welch E, Douglas PS. Physician Attitudes toward the First Pediatric Appropriate Use Criteria and Engagement With Educational Intervention to Improve the Appropriateness of Outpatient Echocardiography. J Am Soc Echocardiogr 2017; 30:926-931.e2. [DOI: 10.1016/j.echo.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Indexed: 01/12/2023]
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Thaden JJ, Tsang MY, Ayoub C, Padang R, Nkomo VT, Tucker SF, Cassidy CS, Bremer M, Kane GC, Pellikka PA. Association Between Echocardiography Laboratory Accreditation and the Quality of Imaging and Reporting for Valvular Heart Disease. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006140. [DOI: 10.1161/circimaging.117.006140] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/21/2017] [Indexed: 11/16/2022]
Abstract
Background—
It is presumed that echocardiographic laboratory accreditation leads to improved quality, but there are few data. We sought to compare the quality of echocardiographic examinations performed at accredited versus nonaccredited laboratories for the evaluation of valvular heart disease.
Methods and Results—
We enrolled 335 consecutive valvular heart disease subjects who underwent echocardiography at our institution and an external accredited or nonaccredited institution within 6 months. Completeness and quality of echocardiographic reports and images were assessed by investigators blinded to the external laboratory accreditation status and echocardiographic results. Compared with nonaccredited laboratories, accredited sites more frequently reported patient sex (94% versus 78%;
P
<0.001), height and weight (96% versus 63%;
P
<0.001), blood pressure (86% versus 39%;
P
<0.001), left ventricular size (96% versus 83%;
P
<0.001), right ventricular size (94% versus 80%;
P
=0.001), and right ventricular function (87% versus 73%;
P
=0.006). Accredited laboratories had higher rates of complete and diagnostic color (58% versus 35%;
P
=0.002) and spectral Doppler imaging (45% versus 21%;
P
<0.0001). Concordance between external and internal grading of external studies was improved when diagnostic quantification was performed (85% versus 69%;
P
=0.003), and in patients with mitral regurgitation, reproducibility was improved with higher quality color Doppler imaging.
Conclusions—
Accredited echocardiographic laboratories had more complete reporting and better image quality, while echocardiographic quantification and color Doppler image quality were associated with improved concordance in grading valvular heart disease. Future quality improvement initiatives should highlight the importance of high-quality color Doppler imaging and echocardiographic quantification to improve the accuracy, reproducibility, and quality of echocardiographic studies for valvular heart disease.
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Affiliation(s)
- Jeremy J. Thaden
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Michael Y. Tsang
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Chadi Ayoub
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T. Nkomo
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Stephen F. Tucker
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Cynthia S. Cassidy
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Merri Bremer
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Garvan C. Kane
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Patricia A. Pellikka
- From the Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Fonseca R, Otahal P, Galligan J, Neilson S, Huynh Q, Saito M, Negishi K, Marwick TH. Association of survival time with transthoracic echocardiography in stable patients with heart failure: Is routine follow-up ever appropriate? Int J Cardiol 2017; 230:619-624. [PMID: 28043666 DOI: 10.1016/j.ijcard.2016.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/14/2016] [Accepted: 12/16/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The appropriateness of repeat transthoracic echocardiography (TTE) for stable heart failure (HF) is based on timing of the follow-up examination, but this lacks scientific support. We sought the association of routine follow-up TTE on survival and readmission in stable HF. METHODS Patients with HF were selected from consecutive HF admissions from 2008 to 2012. Groups were divided into: no follow-up TTE; routine <1year with no change in status ("rarely appropriate"), ≥1year follow-up with no change in status ("maybe appropriate") and TTE due to change in clinical status ("appropriate"). Survival analysis was performed for the combined endpoint of HF readmission and death, and a separate analysis was performed for HF readmission, with death as a competing risk. RESULTS Of 550 HF patients, 141 had a follow-up TTE, including 41 (29%) within 1year. The event-free time in years was similar between no TTE (1.10years [95%CI: 0.69, 1.49], routine TTE <1year (2.61years [95% CI: 1.08, 3.04], routine >1year (2.45years [95% CI: 1.37, 5.78]); all were greater than symptomatic patients (0.09years [95% CI: 0.02, 1.80]). HF readmission was independently associated with statins, renal disease, coronary angiography and NYHA class, but not follow-up TTE timing. There were no differences in the cumulative incidence for death between groups. There were no differences in change in management in routine TTE <1year and ≥1year. CONCLUSION The distinction of appropriateness of routine repeat TTE in stable HF patients, based on testing <1 or ≥1year after index admission appears unjustified.
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Affiliation(s)
| | - Petr Otahal
- Menzies Institute for Medical Research, Hobart, Australia
| | | | | | - Quan Huynh
- Menzies Institute for Medical Research, Hobart, Australia
| | - Makoto Saito
- Menzies Institute for Medical Research, Hobart, Australia
| | | | - Thomas H Marwick
- Menzies Institute for Medical Research, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia.
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Bouma BJ, Riezenbos R, Voogel AJ, Veldhorst MH, Jaarsma W, Hrudova J, Cernohorsky B, Chamuleau S, van den Brink RBA, Breedveld R, Reichert C, Kamp O, Braam R, van Melle JP. Appropriate use criteria for echocardiography in the Netherlands. Neth Heart J 2017; 25:330-334. [PMID: 28247246 PMCID: PMC5405027 DOI: 10.1007/s12471-017-0960-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. Methods All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). Results Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. Conclusions Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity. Electronic supplementary material The online version of this article (doi: 10.1007/s12471-017-0960-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- B J Bouma
- Department of Cardiology, AMC, Amsterdam, The Netherlands.
| | - R Riezenbos
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - A J Voogel
- Department of Cardiology, Spaarne Hospital, Hoofddorp, The Netherlands
| | - M H Veldhorst
- Department of Cardiology, Isala, Zwolle, The Netherlands
| | - W Jaarsma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Hrudova
- Department of Cardiology, St Antonius Hospital, Sneek, The Netherlands
| | - B Cernohorsky
- Department of Cardiology, St Antonius Hospital, Sneek, The Netherlands
| | - S Chamuleau
- Department of Cardiology, University Medical Center, Utrecht, The Netherlands
| | | | - R Breedveld
- Department of Cardiology, MCL, Leeuwarden, The Netherlands
| | - C Reichert
- Department of Cardiology, MCA, Alkmaar, The Netherlands
| | - O Kamp
- Department of Cardiology, VUmc and AMC, Amsterdam, The Netherlands
| | - R Braam
- Department of Cardiology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - J P van Melle
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Promislow S, Abunassar JG, Banihashemi B, Chow BJ, Dwivedi G, Maftoon K, Burwash IG. Impact of a structured referral algorithm on the ability to monitor adherence to appropriate use criteria for transthoracic echocardiography. Cardiovasc Ultrasound 2016; 14:31. [PMID: 27528386 PMCID: PMC4986360 DOI: 10.1186/s12947-016-0075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/04/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Steven Promislow
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Joseph G Abunassar
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Behnam Banihashemi
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Benjamin J Chow
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Girish Dwivedi
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Kasra Maftoon
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ian G Burwash
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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