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Lopez L, Saurers DL, Barker PCA, Cohen MS, Colan SD, Dwyer J, Forsha D, Friedberg MK, Lai WW, Printz BF, Sachdeva R, Soni-Patel NR, Truong DT, Young LT, Altman CA. Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:119-170. [PMID: 38309834 DOI: 10.1016/j.echo.2023.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
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Affiliation(s)
- Leo Lopez
- Department of Pediatrics Cardiology, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California.
| | - Daniel L Saurers
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Piers C A Barker
- Duke Children's Hospital & Health Center, Duke University, Durham, North Carolina
| | - Meryl S Cohen
- Cardiac Center and Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeanine Dwyer
- Pediatric Heart Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Daniel Forsha
- Ward Family Heart Center, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Mark K Friedberg
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Wyman W Lai
- Division of Pediatric Cardiology, University of California School of Medicine, Irvine, California; Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Beth F Printz
- Rady Children's Hospital San Diego and University of California, San Diego, San Diego, California
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Neha R Soni-Patel
- Pediatric & Adult Congenital Heart Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dongngan T Truong
- University of Utah and Division of Pediatric Cardiology, Primary Children's Hospital, Salt Lake City, Utah
| | - Luciana T Young
- Seattle Children's Hospital and Pediatric Cardiology, University of Washington School of Medicine, Seattle, Washington
| | - Carolyn A Altman
- Baylor College of Medicine and Texas Children's Heart Center, Texas Children's Hospital, Houston, Texas
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Scott MW, Metcalf C, Bhadury S, Feygin Y, Neal AE. Impact of COVID-19 pandemic healthcare restrictions on utilisation and diagnostic yield of outpatient transthoracic echocardiograms. Cardiol Young 2023; 33:1936-1941. [PMID: 36380489 DOI: 10.1017/s1047951122003535] [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] [Indexed: 11/18/2022]
Abstract
BACKGROUND During the COVID-19 pandemic, Kentucky prohibited elective medical procedures from 3/18/2020-4/27/2020. We sought to determine if cessation of elective procedures in Kentucky during the COVID-19 pandemic resulted in a decrease in the proportion of rarely appropriate outpatient transthoracic echocardiograms interpreted at the open echocardiography lab at Norton Children's Hospital. METHODS A retrospective chart review was conducted comparing proportions of rarely appropriate outpatient paediatric transthoracic echocardiograms performed pre-COVID (3/21/2019-4/28/2019) and during COVID (3/19/2020-4/27/2020). Transthoracic echocardiogram indication was determined by chart review and echocardiogram reports. Indication appropriateness was evaluated using paediatric appropriate use criteria for initial outpatient transthoracic echocardiogram or CHD follow-up as applicable. RESULTS Of transthoracic echocardiograms pre-COVID, 100 (37.7%) were rarely appropriate versus 18 (20.2%) during COVID. Pre-COVID, paediatric cardiologists tended to order fewer rarely appropriate transthoracic echocardiograms than paediatricians (35.9% versus 46.4%), although this difference was not statistically significant. Cardiologists ordered the majority of outpatient transthoracic echocardiograms during COVID (77/89, 86.5%), limiting the ability to compare transthoracic echocardiogram indications by provider type. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms with (13.0%) abnormal studies pre-COVID versus 7 (15.5%) during COVID. CONCLUSION While elective procedures were prohibited in Kentucky during the COVID-19 pandemic, a decrease in the proportion of rarely appropriate outpatient paediatric transthoracic echocardiograms was observed. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms between time periods, suggesting that clinically significant echocardiogram findings were still detected despite more prudent utilisation of echocardiography during this time.
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Affiliation(s)
- Michael W Scott
- Department of Pediatrics, University of Louisville, Louisville, KY, USA
| | - Christina Metcalf
- Department of Pediatrics, University of Louisville, Louisville, KY, USA
| | - Sagnik Bhadury
- Department of Biostatistics, University of Louisville, Louisville, KY, USA
| | - Yana Feygin
- Norton Children's Research Institute Affiliated with University of Louisville School of Medicine, Louisville, KY, USA
| | - Ashley E Neal
- Department of Pediatrics, University of Louisville, Louisville, KY, USA
- Norton Children's, Louisville, KY, USA
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Patel T, Kelleman M, Pickard S, Miller J, Suthar D, Sachdeva R. Implementation of Appropriate Use Criteria for Transthoracic Echocardiography in Follow up Care of Pediatric Patients with Congenital Heart Disease. J Am Soc Echocardiogr 2022; 35:1084-1090.e19. [PMID: 35568251 DOI: 10.1016/j.echo.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/17/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Indications for transthoracic echocardiography (TTE) from the 2020 Appropriate Use Criteria (AUC) for congenital heart disease (CHD) were incorporated into our electronic ordering system as a clinical decision support tool. The purpose of this study was to evaluate TTE utilization and factors affecting appropriateness of TTE orders during follow-up care of patients with CHD. METHODS All TTEs performed during follow-up clinic visits from 5/1/2020 to 11/30/2020 were included. TTE indications were rated appropriate (A), may be appropriate (M), or rarely appropriate (R) based on the AUC, and unclassifiable if indication was not in the document but related to included lesions. CHD was graded as simple, moderate, and complex based on Bethesda classification. Logistic regression was used to determine association of ratings with patient age, insurance status, CHD complexity, clinician experience and specialty. RESULTS Of the 5158 studies, 3979 (77.2%) were for CHD included in the AUC document, 322 (8%) were unclassifiable, 37 (0.7%) for CHD not in the document, and 1142 (22.1%) for non-CHD indications. Of the 3657 TTEs to which AUC ratings could be applied, 95.6% were A, 2.4% M, and 2.0% R. The highest utilization of TTE was for follow-up of ventricular septal defects, left ventricular outflow tract obstruction, and single ventricles; 46% for unrepaired CHD; 78% for routine surveillance and the remaining for a change in clinical status. On multivariable analysis, the only significant factor associated with M/R ratings was simple CHD [OR 11.58 (95% CI 5.36 - 24.98), p<0.001]. CONCLUSIONS Three-quarters of the TTEs ordered during follow-up care in pediatric cardiology clinics are for indications related to CHD. Most TTEs for follow-up of CHD were for routine surveillance and indications rated A. TTE orders for M/R ratings were associated with simple CHD. Though the 2020 AUC document successfully stratifies majority of indications related to CHD, future documents should consider the unclassifiable CHD indications and the non-CHD indications.
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Affiliation(s)
- Trisha Patel
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA.
| | | | - Sarah Pickard
- Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Jamison Miller
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Divya Suthar
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
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4
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Srnka CM, Strohacker CM, Balasubramanian S, Yu S, Lowery R, Lu JC. Improving adherence to echocardiogram reporting guidelines in patients with repaired tetralogy of fallot: A quality improvement initiative. Echocardiography 2021; 38:596-603. [PMID: 33729621 DOI: 10.1111/echo.15030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/30/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In patients with repaired tetralogy of Fallot (TOF), key echocardiogram report elements have been identified, but poor adherence has been demonstrated, particularly for quantitative assessment. We report a quality improvement effort to improve adherence at our institution, with a focus on increasing quantitative assessment of right ventricular (RV) function. METHODS Baseline compliance was established by a 3-month retrospective review of outpatient echocardiogram reports. Intervention 1 included presenting baseline data and reviewing the guidelines with echocardiogram laboratory staff (physicians and sonographers). Intervention 2, chosen to focus on quantitative assessment of RV function, involved recommending measurement of tricuspid annular plane systolic excursion (TAPSE) for all echocardiograms. Reporting rates were prospectively analyzed for 1 month after each intervention. To evaluate sonographer versus physician compliance, both study images (acquisition of TAPSE images) and reports were reviewed. RESULTS At baseline, adherence was poor (median 65% of elements reported), with lower rates for measurements versus descriptive elements (median 40% vs 78%, p<.0001). Following intervention 1, total reported elements improved (median 71% vs 65%, p=0.02) due to increase in measurements (median 50% vs 40%, p=0.02). Reports of quantitative RV function did not significantly change after either intervention, but sonographer compliance improved after intervention 1 (33% vs 14%, p=0.03), with further improvement after intervention 2 (53% vs 14%, p=0.001). CONCLUSION While education on lesion-specific guidelines may modestly improve adherence, standardization has a greater effect. However, interventions may have differential impact on sonographers versus attendings, and iterative interventions may be required to change practice patterns.
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Affiliation(s)
- Charlotte M Srnka
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Courtney M Strohacker
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sowmya Balasubramanian
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Winchester DE, Merritt J, Waheed N, Norton H, Manja V, Shah NR, Helfrich CD. Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:34-41. [PMID: 32232436 DOI: 10.1093/ehjqcco/qcaa029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/13/2022]
Abstract
AIMS The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. METHODS AND RESULTS We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or 'nudges'. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. CONCLUSION We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. STUDY REGISTRATION PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Malcom Randall VAMC, 1601 SW Archer Rd 111-D, Gainesville, FL, USA.,Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Justin Merritt
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Hannah Norton
- University of Florida College of Medicine, Health Science Center Library, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Veena Manja
- Department of Surgery, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA.,VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA
| | - Nishant R Shah
- Department of Medicine, Providence VA Medical Center, Brown University Warren Alpert Medical School, 830 Chalkstone Ave, Providence, RI 02908, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Christian D Helfrich
- Seattle-Denver Center for Innovation in Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way Mailstop S-152 Seattle, WA 98108, USA
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Application of Appropriate Use Criteria for Echocardiography in Pediatric Patients with Palpitations and Arrhythmias. Pediatr Qual Saf 2020; 5:e364. [PMID: 33134762 PMCID: PMC7591125 DOI: 10.1097/pq9.0000000000000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022] Open
Abstract
Before the integration of the pediatric appropriate use criteria (AUC) for initial transthoracic echocardiography (TTE) in the outpatient setting with our electronic medical record (EMR), there was a high proportion of “rarely appropriate” TTEs (17.2%) ordered for palpitations/arrhythmias. We studied appropriateness ratings and applicability of pediatric AUC on the initial outpatient evaluation of children with palpitations/arrhythmias after EMR integration and the yield of abnormal TTEs for these indications.
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Sachdeva R, Valente AM, Armstrong AK, Cook SC, Han BK, Lopez L, Lui GK, Pickard SS, Powell AJ, Bhave NM, Sachdeva R, Valente AM, Pickard SS, Baffa JM, Banka P, Cohen SB, Glickstein JS, Kanter JP, Kanter RJ, Kim YY, Kipps AK, Latson LA, Lin JP, Parra DA, Rodriguez FH, Saarel EV, Srivastava S, Stephenson EA, Stout KK, Zaidi AN, Gluckman TJ, Aggarwal NR, Bhave NM, Dehmer GJ, Gilbert ON, Kumbhani DJ, Price AL, Winchester DE, Gulati M, Dehmer GJ, Doherty JU, Bhave NM, Daugherty SL, Dean LS, Desai MY, Gillam LD, Mehrotra P, Sachdeva R, Winchester DE. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Soc Echocardiogr 2020; 33:e1-e48. [PMID: 33010859 DOI: 10.1016/j.echo.2020.04.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The American College of Cardiology (ACC) collaborated with the American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Pediatric Echocardiography to develop Appropriate Use Criteria (AUC) for multimodality imaging during the follow-up care of patients with congenital heart disease (CHD). This is the first AUC to address cardiac imaging in adult and pediatric patients with established CHD. A number of common patient scenarios (also termed "indications") and associated assumptions and definitions were developed using guidelines, clinical trial data, and expert opinion in the field of CHD.1 The indications relate primarily to evaluation before and after cardiac surgery or catheter-based intervention, and they address routine surveillance as well as evaluation of new-onset signs or symptoms. The writing group developed 324 clinical indications, which they separated into 19 tables according to the type of cardiac lesion. Noninvasive cardiac imaging modalities that could potentially be used for these indications were incorporated into the tables, resulting in a total of 1,035 unique scenarios. These scenarios were presented to a separate, independent panel for rating, with each being scored on a scale of 1 to 9, with 1 to 3 categorized as "Rarely Appropriate," 4 to 6 as "May Be Appropriate," and 7 to 9 as "Appropriate." Forty-four percent of the scenarios were rated as Appropriate, 39% as May Be Appropriate, and 17% as Rarely Appropriate. This AUC document will provide guidance to clinicians in the care of patients with established CHD by identifying the reasonable imaging modality options available for evaluation and surveillance of such patients. It will also serve as an educational and quality improvement tool to identify patterns of care and reduce the number of Rarely Appropriate tests in clinical practice.
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Improvement in Appropriateness of Pediatric Outpatient Echocardiography Orders Following Integration of the Appropriate Use Criteria within the Electronic Medical Record Ordering System. J Am Soc Echocardiogr 2020; 33:1152-1153. [PMID: 32624318 DOI: 10.1016/j.echo.2020.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/21/2022]
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Stern KWD, McCracken CE, Gillespie SE, Lang SM, Statile CJ, Lopez L, Verghese GR, Choueiter NF, Sachdeva R. Physician variation in ordering of transthoracic echocardiography in outpatient pediatric cardiac clinics. Echocardiography 2020; 37:1056-1064. [DOI: 10.1111/echo.14756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kenan W. D. Stern
- Icahn School of Medicine at Mount Sinai Children’s Heart Center Kravis Children’s Hospital New York New York USA
| | | | - Scott E. Gillespie
- Department of Pediatrics Emory University School of Medicine Atlanta GeorgiaUSA
| | - Sean M. Lang
- The Heart Institute Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Christopher J. Statile
- The Heart Institute Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Leo Lopez
- Stanford School of Medicine Betty Irene Moore Children's Heart Center Lucile Packard Children’s Hospital Palo Alto California USA
| | - George R. Verghese
- Northwestern University Feinberg School of Medicine The Heart Center Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago Illinois USA
| | - Nadine F. Choueiter
- Albert Einstein College of Medicine Pediatric Heart Center The Children’s Hospital at Montefiore Bronx New York USA
| | - Ritu Sachdeva
- Sibley Heart Center Cardiology Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
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Annavajjhala V, Valente AM, Lopez L, Sachdeva R, Glickstein JS, Natarajan SS, Buddhe S, Altmann K, Soriano BD, Colquitt JL, Altman CA, Sasaki N, Sakarovitch C, Tacy TA, Geva T, Selamet Tierney ES. Echocardiographic surveillance in children after tetralogy of Fallot repair: Adherence to guidelines? Int J Cardiol 2020; 307:31-35. [DOI: 10.1016/j.ijcard.2019.09.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/14/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022]
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Renno MS, Lambert AN, Kannankeril P, Johnson DP, Parra DA. Impact of Clinician Engagement on Implementation of the Pediatric Echocardiography Appropriate Use Criteria. Pediatr Cardiol 2020; 41:553-560. [PMID: 31938843 PMCID: PMC8182407 DOI: 10.1007/s00246-020-02284-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
We sought to determine whether awareness of the pediatric appropriate use criteria (AUC) affected transthoracic echocardiogram (TTE) ordering by cardiologists; evaluate for differences in classification of an encounter's AUC clinical scenario by investigator chart review compared with clinicians at the time of the encounter; and assess TTE yield by appropriateness rating. AUC clinical scenario(s) were assigned to patients without prior TTE by investigator chart review of visits in 2014 (n = 209) and 2016 (n = 199), and by clinician classification in 2016 (n = 671). Investigators documented TTE utilization and findings. Between 2014 and 2016, TTE utilization decreased from 54 to 33% (p < 0.001) of "rarely appropriate" (R) encounters, resulting in a decrease in overall TTE utilization from 73 to 55% of encounters (p < 0.001). There was only moderate agreement of AUC appropriateness by investigator chart review and clinician classification (κ = 0.533, p < 0.001). Abnormal TTE findings were detected in 18.7% of R encounters, with 21 of 24 abnormalities in infants younger than 4 months presenting with murmur. A decrease in TTE utilization for R encounters may represent a change in practice from increased awareness of the AUC. AUC scenario classification by clinicians at the time of the encounter could be superior to chart review. TTE abnormalities may be missed in infants younger than 4 months of age when evaluated for murmurs with the AUC.
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Affiliation(s)
- Markus S. Renno
- Section of Pediatric Cardiology, Department of Pediatrics at Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, 1 Children’s Way, Slot 512-3, Little Rock, AR 72202, USA
| | - A. Nicole Lambert
- Division of Pediatric Cardiology, Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince Kannankeril
- Division of Pediatric Cardiology, Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David P. Johnson
- Division of Pediatric Hospital Medicine, Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A. Parra
- Division of Pediatric Cardiology, Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Sachdeva R, Valente AM, Armstrong AK, Cook SC, Han BK, Lopez L, Lui GK, Pickard SS, Powell AJ, Bhave NM, Sachdeva R, Valente AM, Pickard SS, Baffa JM, Banka P, Cohen SB, Glickstein JS, Kanter JP, Kanter RJ, Kim YY, Kipps AK, Latson LA, Lin JP, Parra DA, Rodriguez FH, Saarel EV, Srivastava S, Stephenson EA, Stout KK, Zaidi AN. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol 2020; 75:657-703. [PMID: 31918898 DOI: 10.1016/j.jacc.2019.10.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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13
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Balasubramanian S, Ramirez FD, Bui Y, Selamet Tierney ES, Behera SK. Comparison of Initial Pediatric Outpatient Echocardiogram Indications between Community and Academic Practice. J Pediatr 2019; 207:23-28.e2. [PMID: 30661793 DOI: 10.1016/j.jpeds.2018.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital. STUDY DESIGN Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings. RESULTS Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008). CONCLUSION The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.
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Affiliation(s)
- Sowmya Balasubramanian
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Faustine D Ramirez
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Yen Bui
- Division of Cardiology, Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, CA
| | - Elif Seda Selamet Tierney
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Sarina K Behera
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA; Pediatric Cardiology, Packard Children's Health Alliance, Stanford Children's Health, San Francisco, CA
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14
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Regan W, Hothi D, Jones K. Sustainable approach to reducing unnecessary combined biochemistry tests on a paediatric cardiology ward. BMJ Open Qual 2018; 7:e000372. [PMID: 30397659 PMCID: PMC6203018 DOI: 10.1136/bmjoq-2018-000372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/13/2018] [Indexed: 11/25/2022] Open
Abstract
We describe a quality improvement project (QIP) designed to reduce unnecessary biochemistry samples requested on a paediatric cardiology ward in Great Ormond Street Hospital. Prior to the intervention biochemistry tests were requested on a daily basis by nursing and junior doctor staff at an annual cost of around £27 000 for the ward. The lead author observed that for the majority the true indication for these biochemistry tests was for the purpose of monitoring renal function and plasma electrolytes. However, during a diagnostic analysis trying to understand the behaviours around ordering tests it appeared that a broader profile and more expensive combined test set was being requested that included unnecessary liver and bone profile analyses. A driver diagram identified three areas to target in order to rationalise blood test requests: (1) a critical understanding of the purpose of the test by those requesting the tests; (2) effective communication between professionals; and (3) improved utilisation of the computer system. An education-based QIP was initiated with the aim of reducing requests of these costly, unnecessary combined biochemical tests by half, by supporting and encouraging staff to switch to a simpler renal function assay. The project was designed to be engaging and fun and invited clinical teams to consider the cost of wasted resources in terms of the financial implications for the hospital, and in terms of the wider environmental impact of wasted resources illustrated in terms of estimated carbon dioxide use. This perhaps unusual approach of encouraging an awareness of both financial and environmental cost led to a sustained reduction in the ordering of expensive combined biochemical tests, saving an estimated £11 338 (or 13.5%) on biochemistry tests and around 17.8 tonnes of carbon dioxide across a 32-month follow-up period.
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Affiliation(s)
- William Regan
- Paediatric Cardiology Department, Great Ormond Street Hospital, London, UK
| | - Daljit Hothi
- Paediatric Cardiology Department, Great Ormond Street Hospital, London, UK
| | - Kevin Jones
- Quality Improvement Team, Great Ormond Street Hospital, London, UK
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15
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Anderson S, McCracken CE, Sachdeva R. Appropriateness of pediatric outpatient transthoracic echocardiogram orders following cessation of an active educational intervention. CONGENIT HEART DIS 2018; 13:1050-1057. [PMID: 30294873 DOI: 10.1111/chd.12679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/30/2018] [Accepted: 08/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The educational intervention (EI) through the Pediatric Appropriate Use of Echocardiography (PAUSE) multicenter study resulted in improved appropriateness of transthoracic echocardiogram (TTE) orders at our center. The current study evaluated if this pattern persisted after cessation of EI and the potential physician characteristics influencing appropriateness. DESIGN Outpatients (≤18 years old) seen for initial evaluation during the EI (July to October, 2015) and 6-month post-EI (May to August, 2016) phases were included. Comparison was made between TTE rates and appropriateness ratings during EI and post-EI phase. Association between TTE rate and appropriateness with physician characteristics (age, experience, patient volume, and area of practice) was determined using odds ratio. RESULTS The study included 7781 patients (EI: N = 4016; post-EI: N = 3765) seen by 31 physicians. Comparison of appropriateness ratings in a randomized sample (EI: N = 1270; post-EI: N = 1325 patients) showed no significant differences between the two phases (appropriate: 75.2% vs 74.9%, P = .960; rarely appropriate 4.1% vs 6.5%, P = .065). Though there was significant variability among physicians for TTE order appropriateness (P = .044) and ordering rate (P <.001), none of their characteristics were associated with appropriateness and only a higher patient volume was associated with decreased odds of TTE ordering (OR =0.7). CONCLUSION The PAUSE study EI resulted in maintaining appropriate utilization of TTEs at our center for 6 months following its cessation. Though not statistically significant, there was a trend toward increase in the proportion of studies for indications designated rarely appropriate (R). There was significant physician variability in TTE ordering and appropriateness during both phases. Development of EI to reduce physician variability and integration of EI with provider workflow may help sustain appropriate TTE utilization.
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Affiliation(s)
- Shae Anderson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Courtney E McCracken
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
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16
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Dalal NN, Dzelebdzic S, Frank LH, Clauss SB, Mitchell SJ, Aljohani OA, Bradley-Hewitt T, Harahsheh AS. Recurrent Cardiology Evaluation for Innocent Heart Murmur: Echocardiogram Utilization. Clin Pediatr (Phila) 2018; 57:1436-1441. [PMID: 29993270 DOI: 10.1177/0009922818787280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We conducted a retrospective study to identify electrocardiogram (ECG) and echocardiogram utilization among patients presenting for a follow-up cardiology evaluation with innocent heart murmur between 2012 and 2014. The 2014 echocardiogram Appropriate Use Criteria was applied. We observed high rates of ordering ECGs and echocardiograms on follow-up visits (79% and 36%); only 1 patient had an appropriate indication for echocardiogram while the rest had rarely appropriate indication. Having had an ECG done did not affect echocardiogram ordering behavior. Older patient age was the only factor associated with a higher likelihood for ordering echocardiograms on follow-up visit (odds ratio = 1.016, P = .021). In this small sample study, we noticed high rates of test utilization and low-probability utilization of echocardiogram in the recurrent evaluation of children with innocent heart murmur. A larger, multicenter prospective study to investigate patterns and drivers of test utilization in children with innocent heart murmur presenting for a follow-up cardiology visit is needed.
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Affiliation(s)
- Nupur N Dalal
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | | | - Lowell H Frank
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Sarah B Clauss
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | | | - Othman A Aljohani
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Tyler Bradley-Hewitt
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Ashraf S Harahsheh
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
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17
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Abstract
BACKGROUND Although transthoracic echocardiography is the dominant imaging modality in CHD, optimal utilisation is unclear. We assessed whether adherence to the paediatric Appropriate Use Criteria for outpatient transthoracic echocardiography could reduce inappropriate use without missing significant cardiac disease. METHODS Using the Appropriate Use Criteria, we determined the indication and appropriateness rating for each initial echocardiogram performed at our institution during calendar year 2014 (N=1383). Chart review documented ordering provider training, patient demographics, and study result, classified as normal, abnormal, or abnormal motivating treatment within a 2-year follow-up period. We tested whether provider training level or patient age correlated with echocardiographic findings or appropriateness rating. RESULTS We found that 83.9% of echocardiograms were normal and that 66.7% had an appropriate indication. Nearly all abnormal results and all results motivating treatment were in appropriate studies, giving an odds ratio of 2.73 for an abnormal result if an appropriate indication was present (95% confidence interval 1.92-3.89, p<0.001). None of the remaining initial abnormal results with less than appropriate indications became significant, resulting in treatment over 2 years. Results suggest a potential reduction in imaging volume of as much as 33% with application of the criteria. Cardiologists ordered nearly all studies resulting in treatment but also more echocardiograms with less appropriate indications. Most examinations were in older patients; however, most abnormal results were in patients younger than 1 year. CONCLUSIONS The Appropriate Use Criteria can be used to safely reduce echocardiography volume while still detecting significant heart disease.
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18
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Stern KWD, Gulesserian T, Choi J, Lang SM, Statile CJ, Michelfelder EC, McLaughlin ES, Nguyen T, Lopez L, Verghese GR, Hsu DT, Sachdeva R. Factors Influencing Pediatric Outpatient Transthoracic Echocardiography Utilization Before Appropriate Use Criteria Release: A Multicenter Study. J Am Soc Echocardiogr 2017; 30:1225-1233. [PMID: 29202952 DOI: 10.1016/j.echo.2017.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) are available, little is known about TTE utilization patterns before their release. The aims of this study were to determine the relation between AUC and TTE utilization and to identify patient and physician factors associated with discordance between the AUC and clinical practice. METHODS A retrospective review of 3,000 initial outpatient pediatric cardiology encounters at six centers was performed. Investigator-determined indications were classified using AUC definitions. Concordance between AUC and TTE utilization was determined. Multivariate analysis was performed to identify patient and physician factors associated with TTE's being performed for rarely appropriate and TTE's not being performed for appropriate indications. RESULTS Concordance between AUC and TTE utilization was 88%. TTE was performed for rarely appropriate indications in 9% and was associated with patient age < 3 months, indications of murmur, noninvasive imaging physician subspecialty, and physician volume. No TTE was ordered for appropriate indications in 3% and was associated with indications including prior test result (primarily abnormal electrocardiographic findings), older patients, and physician subspecialty other than generalist or imaging. There was high variability in TTE utilization among centers. CONCLUSIONS There was a reasonable degree of concordance between AUC and clinical practice before AUC publication. Several patient and physician factors were associated with discordance with the AUC. These findings should be considered in efforts to disseminate the AUC and in the development of future iterations. The causes for variation among centers deserve further exploration.
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Affiliation(s)
- Kenan W D Stern
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York.
| | - Talin Gulesserian
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York
| | - Jaeun Choi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Sean M Lang
- Pediatric Cardiology Section, Arkansas Children's Hospital, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas
| | - Christopher J Statile
- Cincinnati Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik C Michelfelder
- Cincinnati Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ericka S McLaughlin
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Tuan Nguyen
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, Florida International University College of Medicine, Miami, Florida
| | - Leo Lopez
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, Florida International University College of Medicine, Miami, Florida
| | - George R Verghese
- Section of Pediatric Cardiology, Brenner Children's Hospital, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York
| | - Ritu Sachdeva
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University School of Medicine and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
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19
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Kourtidou S, Evers PD, Jorgensen NW, Kronmal RA, Lewin MB, Schultz AH. Pediatric Appropriate Use Criteria for Outpatient Echocardiography: Practice Variations among Pediatric Cardiologists, Noncardiologist Subspecialists, and Primary Care Providers. J Am Soc Echocardiogr 2017; 30:1214-1224. [DOI: 10.1016/j.echo.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 11/26/2022]
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20
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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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