Utilization of echocardiography by internists and cardiologists: a comparative study

Radiological outpatient' visits to avoid inappropriate cardiac CT examinations: an 8-year experience report

PURPOSE

The aim of this study was to evaluate the appropriateness of the cardiac computed tomography angiography (CCTA) prescriptions according to the "2010-Appropriate-Use-Criteria-for-Cardiac-Computed-Tomography-Angiography" (AUCCTA) and "Clinical-indication-for-CCTA" (CICCTA) among different specialities (Cardiologist [CA], General Practitioner [GP], Other Specialists [OS]) and prescribers' age.

MATERIALS AND METHODS

This is a single-centre, single-arm, cohort study. We prospectively enrolled 815 patients (October 2012-May 2019) who underwent a radiological outpatient visit, before CCTA examination. Prescriptions to the examination were categorized as follows: Appropriate (A), Uncertain (U) and Inappropriate (Ina), according to AUCCTA and I, II, III and Inv for CICCTA. This categorization was stratified according to CA, GP and OS and prescribers' age. CCTA was performed in patients whom indications belong to A/U categories.

RESULTS

Eight hundred and fifteen CCTA prescriptions were analysed. An yearly increase in prescriptions was found in the eight-year observational period (2012/2019 projection: 72 vs 223). Considering AUCCTA, indication A was 540/815 (66.3%), indication U was 113/815 (13.9%) and Ina accounted for 162/815 (19.9%; 128/162 [79.0%] indications with stress test listed as criterium of inappropriateness). Only U indications decreased over years (p = 0.003). Regarding CICCTA, 501/815 (61.5%) patients were categorized as I, 144/815 (17.7%) as II, 102/815 (12.5%) as III, 67/815 (8.2%) were INV and 1/815 (0.1%) were non-classified. Clinical referrals were CA in 495/786 (63.0%), GPs in 57/786 (7.3%) GP and OS in 234/786 (29.8%) [p < 0.01]. No statistically significant differences were observed in the appropriateness among different specialty physicians. Younger doctors have a lower chance to not meet A indication (OR 0.98 [CI 95% 0.96-0.99]; p = 0.003).

CONCLUSION

Our study highlights the importance of a pre-radiological visit prior to CCTA, which prevented execution of 19.9% of inappropriate examinations. Age of prescribers had an impact on appropriateness, with younger doctors having a lower chance to not meet A indication.

Neuroimaging: a new training issue in psychiatry?

Many studies recently have highlighted the role of neuroimaging in the diagnosis and management of patients with psychiatric disorders (Lewis, 1996; Costa et al, 1999; Longworth et al, 1999). In old age psychiatry, a diagnosis of dementia is facilitated by structural and functional imaging, both of which have been shown to increase the accuracy with which a diagnosis of Alzheimer's disease can be made (Zakzanis et al, 2003). There is also a role for neuroimaging in the differential diagnosis of organic brain syndromes, which are often referred to the old age and liaison psychiatric services. The usefulness of neuroimaging has extended further into the area of the major functional psychiatric disorders by contributing to our understanding of the aetiology and pathophysiology of these illnesses. Despite this, image interpretation has not yet been incorporated into the training of psychiatrists, at junior or senior level. In this, we differ from other specialist areas of medicine where the ability to interpret images is an integral part of training. At present, the Royal College of Psychiatrists is developing a competency-based curriculum for senior trainees that will lead to the certificate of completion of training (CCT). This will replace the existing CCST (certificate of completion of specialist training; http://www.rcpsych.ac.uk/traindev/postgrad/ccst.htm). In order to obtain the CCT, a series of ‘general competencies' will be recommended for all senior trainees, which will involve the trainee developing expertise in a number of roles identified by the College. These include the roles of clinician, researcher and educator, among others. Specific key competencies will be further recommended in the development of these general competencies, with variations in some key competencies according to the sub-specialty.

Short training in focused cardiac ultrasound in an Internal Medicine department: what realistic skill targets could be achieved?

The importance of focused cardiac ultrasound (FCU) in Internal Medicine care has been recognized by the American Society of Echocardiography. The aim of this study was to test what realistic skill targets could be achieved in FCU, with a relatively short training (theoretical and practical) of 9 h offered to Internal Medicine certification board attending students, and if the addition of further 9 h of training could significantly improve the level of competence. Kappa statistic was used to calculate the inter-observer agreement (trainees/tutor). The agreement between the trainees (who completed the entire training) and the tutor was, respectively, "substantial" (k = 0.71) for the identification of pericardial effusion, "moderate" (k = 0.56-0.54) for the identification of marked right ventricular and left ventricular enlargement, "substantial" (k = 0.77) for the assessment of global cardiac systolic function by visual inspection and "fair" (k = 0.35) for the assessment of size and respiratory change in the diameter of the inferior cave vein (IVC). 18 h training in FCU provided proficiency in obtaining adequate images from the parasternal window without providing the ability to correctly master the apical and subcostal windows. As concerns the interpretative skills, only pericardial effusion and visual estimation of global systolic function could be correctly identified, while ventricular enlargement and IVC prove to be more difficult to evaluate. This study supports incorporating FCU into Internal Medicine fellowship training programs, and should facilitate the design of other similar training courses.

Clinical utility of guideline-based echocardiography: a prospective study of outpatient referral patterns at a tertiary care center

BACKGROUND

The spread of echocardiography has increased the number of requests for echocardiography and the length of patient waiting lists in National Health Systems. This overuse of echocardiography may also result in a decrease in examination quality because of an excess in workload. The recommended use of guidelines for the requesting of echocardiograms could reduce the demand for this investigation and thus reduce both workload and health care costs.

METHODS

In a prospective study of 520 outpatients in a large tertiary referral center, we analyzed adherence by family physicians and cardiovascular specialists to published guidelines for requesting echocardiograms; the use of a written indication justifying the request for the first and subsequent examinations; the diagnostic outcome; and the clinical utility of each echocardiogram performed.

RESULTS

Most echocardiograms (72%) were requested by specialists, follow-ups were frequent (72%), and 14% of these proved normal. Among first examinations, 49% of those requested by family physicians and 36% of those requested by specialists were normal (P = not significant [NS]); in both groups 27% of the requests lacked a written indication. Family physicians requested echocardiograms chiefly for arterial hypertension, palpitations, chest pain, and valve disease, whereas specialists most often requested echocardiograms for checking valve prostheses, ischemic heart disease, and valve disease. The rate of adherence to guidelines (54% vs 52%, P = NS) and clinical utility (60% vs 61%, P = NS) was low and similar for family physicians and specialists. Provision of a written indication for the examination by the requesting physician correlated strongly to the clinical utility of the test (P < .001), and adherence of indication to guidelines was the major determinant of clinical utility at logistic regression analysis (P < .001).

CONCLUSION

The rate of adherence to guidelines was lower than desirable and similar for family physicians and cardiovascular specialists. Adherence to guidelines and provision of a written specific indication strongly enhanced the value of the echocardiographic investigation.

Supervised echocardiography in internal medicine. An integrated model in a community hospital

Background: The management of patients admitted to an internal medicine ward frequently requires echocardiography, which may often be delayed because of overburdened specialist cardiologist services. The availability of appropriate echocardiography may be improved if internists first perform autonomous echocardiography on their cardiac patients. Our 5-year experience with such a model shows how it can exploit the complementary role of internists and cardiologists. Methods: We analysed data collected prospectively over 5 years, including patient characteristics, indications for investigation, time of execution, echocardiographic findings, incidence of technical failures and incomplete reports, and need for expert consultation, supervision, and review. Results: Out of 6035 admitted patients, 1943 (32%) had a primary cardiac discharge diagnosis and 1158 (19%) underwent transthoracic echocardiography (54% male, mean age 70.2+/-10.3 years). Heart failure, atrial fibrillation/flutter, and chest pain were the most frequent indications (19%, 14%, and 12% of cases, respectively). Technical failure occurred in 31 cases (2.7%) and incomplete information was provided in 127 cases (11%). Valvular and coronary heart diseases were the most frequent echocardiographic diagnoses (27% and 15%, respectively). Expert supervision, consultation, or review was required in 21 of the examinations (1.8%). Conclusion: Internists with training in echocardiography and adequate access to expert consultation can provide timely and clinically profitable echocardiographic information for the majority of their cardiac patients. The improved selection of their referrals allows cardiologists more time to devote themselves to detecting expertise-demanding pathology using special echocardiographic procedures. This integrated model can be applied in various clinical settings.

Is cardiology consultation required before cardiac catheterization?

Background: In many hospitals, internists have begun to directly refer patients for cardiac catheterization without a prior cardiology consultation. The purpose of this study is to compare the results of a policy of mandatory consultation prior to catheterization with one of optional consultation. Methods: One hundred seventy-five consecutive patients who underwent catheterization with a prior cardiology consultation (closed group) were compared to 175 patients who underwent the procedure without a prior mandatory consultation (open group). The primary outcomes were defined as whether significant coronary disease was found and what therapy the patient received. Results: There was no difference in the percentage of patients who were found to have coronary disease in each group (72% in the closed group and 77% in the open group, P=NS), and there was also no difference in the percentage of patients who received revascularization therapy (43% in the closed group and 44% in the open group, P=NS). Conclusions: Allowing internists to refer patients directly for catheterization resulted in equivalent results as compared to requiring cardiology consultation. This study supports the policy of allowing direct referral for catheterization, but further studies are needed to compare the outcomes of cardiac patients cared for by hospitalists without cardiology consultation.

A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States

PURPOSE

To assess the effects of physician specialty on the knowledge, management, and outcomes of patients with coronary disease or heart failure.

MATERIALS AND METHODS

We performed a systematic search of MEDLINE from 1980 to 1997, as well as bibliographic references to articles about the effects of physician specialty on the knowledge, treatment, and outcomes of patients with coronary disease or heart failure in the United States.

RESULTS

Twenty-four articles met our criteria for inclusion (including eight that involved knowledge or self-reported practices, 14 that described actual practice patterns, and six that measured clinical outcomes). Cardiologists were more knowledgeable than generalist physicians about the optimal evaluation and management of coronary disease but not about the use of angiotensin-converting enzyme (ACE) inhibitors for heart failure. Patients with unstable angina or myocardial infarction were more likely to receive proven medical therapies, and possibly had improved outcomes, if they were treated by cardiologists. The use of lipid-lowering drugs after myocardial infarction was also more common among patients of cardiologists. ACE inhibitor use for heart failure was probably greater, and short-term readmission rates were lower, with cardiology care.

CONCLUSIONS

Patients with coronary disease or heart failure in the United States who are treated by cardiologists appear more likely to receive evidence-based care and probably have better outcomes. Investigation of collaborative models of care and innovative efforts to improve the use of proven therapies by physicians are needed.

Ordering an echocardiogram for evaluation of left ventricular function: level of expertise necessary for efficient use

This prospective study was performed to test the hypothesis that the yield of 2-dimensional echocardiography (2DE) would be higher when it is ordered by a cardiologist than by a noncardiologist. Patients referred for transthoracic 2DE for the evaluation of left ventricular systolic function for the 11-month period between July 10, 1995, and June 10, 1996, were included in the study. Demographic, historical, and clinical findings were recorded. Whether the patient was referred by a cardiologist versus a noncardiologist was used as the predictor variable in a binary logistic regression analysis. To address the possibility that the yield of 2DE may be higher for cardiologists because the prevalence of disease in patients referred to them may be higher (selection bias), the analysis was subjected to a propensity score adjustment. Of 2176 patients referred for 2DE during the study, 1033 were referred for the evaluation of left ventricular function. The test had a positive yield in 52% of patients for cardiologists versus 31% for noncardiologists (chi(2) = 45.5, P <.0001, odds ratio 2.4 [CI = 1. 9-3.1]). This difference remained highly significant even when propensity score risk adjustment was made (chi(2) = 54.2, P <.0001, odds ratio 2.0 [CI = 1.5-2.8]). We conclude that the yield of 2DE is higher for cardiologists compared with noncardiologists and that this result was not related to differences in patient populations examined by the two groups. Thus, more efficient use of 2DE may be achieved if patients are referred to cardiologists rather than directly sent for 2DE.

Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure

BACKGROUND

Heart failure (HF) is responsible for considerable mortality morbidity rates and resource utilization. Recently, several studies have reported improved outcomes when patients are managed by special HF clinics, but it is uncertain whether this improvement reflects differences in physician practices or other aspects of the operation of these clinics.

OBJECTIVES

This study was designed to identify differences in HF management practices between general cardiologists and cardiologists specializing in the treatment of patients with HF.

METHODS

A survey examining diagnostic and treatment practices in patients with HF was sent to a sample of cardiologists derived from the American Medical Association Masterfile and to HF specialists who were members of the Society of Transplant Cardiologists or principal investigators in HF trials. Responses were examined in relation to guidelines issued by the Agency for Health care Policy and Research released 9 months previously.

RESULTS

In general both groups practice in conformity with published guidelines. However, there were important differences between the practice patterns of general cardiologists and HF specialists. For instance, in patients being evaluated for the first time, cardiologists reported using a chest radiograph to assist in the diagnosis more than did HF specialists (47% vs 12%), whereas HF specialists were more likely to use an echocardiogram (73% vs 48%). Both groups were likely to evaluate their patients for ischemia and possible revascularization, even in patients not having angina. However, HF specialists tended to use coronary angiography as the initial diagnostic test, whereas cardiologists were more likely to use stress testing. HF specialists more often used angiotensin-converting enzyme inhibitors as part of their initial therapy in patients with mild to moderate HF (94% vs 86%) and during maintenance therapy (91% vs 80%). Also, HF specialists were more likely than cardiologists to titrate angiotensin-converting enzyme inhibitors to higher doses (75% vs 35%), even in the presence of renal dysfunction.

CONCLUSION

Cardiologists and HF specialists generally manage their patients in conformity with guidelines. However, in many areas, such as angiotensin-converting enzyme inhibitor use, HF specialists do so more aggressively. These approaches may, in part, explain the success of the HF clinic model and raise the possibility that some portion of the HF population may be more optimally managed by cardiologists with a special interest in and additional training or experience with this condition.