1
|
Balasubramanian S, Yu S, Behera SK, Bhat AH, Camarda JA, Choueiter NF, Jone P, Lopez L, Natarajan SS, Parra DA, Parthiban A, Sachdeva R, Srivastava S, Tierney ESS. Consensus-Based Development of a Pediatric Echocardiography Complexity Score: Design, Rationale, and Results of a Quality Improvement Collaborative. J Am Heart Assoc 2024; 13:e029798. [PMID: 38390878 PMCID: PMC10944062 DOI: 10.1161/jaha.123.029798] [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: 02/10/2023] [Accepted: 11/07/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The complexity of congenital heart disease has been primarily stratified on the basis of surgical technical difficulty, specific diagnoses, and associated outcomes. We report on the refinement and validation of a pediatric echocardiography complexity (PEC) score. METHODS AND RESULTS The American College of Cardiology Quality Network assembled a panel from 12 centers to refine a previously published PEC score developed in a single institution. The panel refined complexity categories and included study modifiers to account for complexity related to performance of the echocardiogram. Each center submitted data using the PEC scoring tool on 15 consecutive inpatient and outpatient echocardiograms. Univariate and multivariate analyses were performed to assess for independent predictors of longer study duration. Among the 174 echocardiograms analyzed, 68.9% had underlying congenital heart disease; 44.8% were outpatient; 34.5% were performed in an intensive care setting; 61.5% were follow-up; 46.6% were initial or preoperative; and 9.8% were sedated. All studies had an assigned PEC score. In univariate analysis, longer study duration was associated with several patient and study variables (age <2 years, PEC 4 or 5, initial study, preoperative study, junior or trainee scanner, and need for additional imaging). In multivariable analysis, a higher PEC score of 4 or 5 was independently associated with longer study duration after controlling for study variables and center variation. CONCLUSIONS The PEC scoring tool is feasible and applicable in a variety of clinical settings and can be used for correlation with diagnostic errors, allocation of resources, and assessment of physician and sonographer effort in performing, interpreting, and training in pediatric echocardiography.
Collapse
Affiliation(s)
| | - Sunkyung Yu
- Department of PediatricsUniversity of MichiganAnn ArborMIUSA
| | | | - Aarti H. Bhat
- Department of PediatricsUniversity of Washington and Seattle Children’s HospitalSeattleWAUSA
| | - Joseph A. Camarda
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoILUSA
| | | | - Pei‐Ni Jone
- Department of PediatricsLurie Children’s HospitalChicagoILUSA
| | - Leo Lopez
- Department of PediatricsStanford School of MedicinePalo AltoCAUSA
| | - Shobha S. Natarajan
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - David A. Parra
- Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Anitha Parthiban
- Texas Children’s Hospital, Baylor College of MedicineHoustonTXUSA
| | - Ritu Sachdeva
- Emory University and Children’s Healthcare of AtlantaAtlantaGAUSA
| | | | | |
Collapse
|
2
|
Villafane J, Miller JR, Glickstein J, Johnson JN, Wagner J, Snyder CS, Filina T, Pomeroy SL, Sexson-Tejtel SK, Haxel C, Gottlieb J, Eghtesady P, Chowdhury D. Loss of Consciousness in the Young Child. Pediatr Cardiol 2021; 42:234-254. [PMID: 33388850 DOI: 10.1007/s00246-020-02498-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/07/2020] [Indexed: 01/03/2023]
Abstract
In the very young child (less than eight years of age), transient loss of consciousness represents a diagnostic and management dilemma for clinicians. While most commonly benign, syncope may be due to cardiac dysfunction which can be life-threatening. It can be secondary to an underlying ion channelopathy, cardiac inflammation, cardiac ischemia, congenital heart disease, cardiomyopathy, or pulmonary hypertension. Patients with genetic disorders require careful evaluation for a cardiac cause of syncope. Among the noncardiac causes, vasovagal syncope is the most common etiology. Breath-holding spells are commonly seen in this age group. Other causes of transient loss of consciousness include seizures, neurovascular pathology, head trauma, psychogenic pseudosyncope, and factitious disorder imposed on another and other forms of child abuse. A detailed social, present, past medical, and family medical history is important when evaluating loss of consciousness in the very young. Concerning characteristics of syncope include lack of prodromal symptoms, no preceding postural changes or occurring in a supine position, after exertion or a loud noise. A family history of sudden unexplained death, ion channelopathy, cardiomyopathy, or congenital deafness merits further evaluation. Due to inherent challenges in diagnosis at this age, often there is a lower threshold for referral to a specialist.
Collapse
Affiliation(s)
- Juan Villafane
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital, Cincinnati, OH, USA. .,Department of Pediatrics, 743 East Broadway, Suite 300, Louisville, KY, 40202, USA.
| | - Jacob R Miller
- Department of Surgery, Division of Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Glickstein
- Department of Pediatrics, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jonathan N Johnson
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Wagner
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Chris S Snyder
- Congenital Heart Collaborative, Rainbow Babies and Children's Hospital, Case Western University, Cleveland, OH, USA
| | - Tatiana Filina
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott L Pomeroy
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Caitlin Haxel
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Pirooz Eghtesady
- Department of Surgery, Division of Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | | |
Collapse
|
3
|
Augoustides JG. Perioperative Echocardiography During the Coronavirus Crisis: Considerations in Pediatrics and Congenital Heart Disease. J Cardiothorac Vasc Anesth 2020; 34:2303-2306. [PMID: 32387016 PMCID: PMC7165086 DOI: 10.1053/j.jvca.2020.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 12/22/2022]
Affiliation(s)
- John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Pelletier JH, Blanchard S, Chamberlain RC, Hornik CP, Campbell MJ, Hill KD. The Use of Echocardiography for Pediatric Patients Presenting with Syncope. J Pediatr 2017; 190:43-48. [PMID: 28888565 DOI: 10.1016/j.jpeds.2017.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/08/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess the frequency, yield, and cost of echocardiograms meeting "rarely appropriate" criteria. STUDY DESIGN Retrospective, single-center study of pediatric patients presenting with syncope. Patients were categorized according to the appropriate use criteria and based upon location of care (emergency department only, primary care setting only, or referred to a pediatric cardiologist). Multivariable regression was used to determine factors associated with performance of a "rarely appropriate" echocardiogram. Costs were calculated using fair market values from the Healthcare Bluebook. RESULTS The cohort included 637 patients presenting with syncope during the 1-year study. Echocardiograms were ordered for 127 of 637 (20.1%) including 0 of 328 emergency department patients, 1 of 66 (1.5%) primary care setting patients, and 127 of 243 (52.3%) patients evaluated by a pediatric cardiologist. Use of echocardiography by pediatric cardiologists was categorized as "appropriate" in 92 of 127 (72.4%), "maybe appropriate" in 6 of 127 (4.7%), and "rarely appropriate" in 29 of 127 (22.8%). Abnormal findings were seen in 6 of 127 (4.7%) echocardiograms but in none of the "rarely appropriate" studies. In multivariable analysis, female sex and younger age were the only factors associated with performance of a "rarely appropriate" echocardiogram. "Rarely appropriate" echocardiograms cost an estimated $16 704.00 ($576.00 per patient) in the 1-year study. CONCLUSIONS "Rarely appropriate" echocardiograms performed for syncope do not contribute management changing diagnostic information. However, they burden patients with additional cost and perhaps contribute to increased need for follow-up.
Collapse
Affiliation(s)
| | | | | | | | | | - Kevin D Hill
- Duke University Hospital and Health Center, Durham, NC
| |
Collapse
|
6
|
Chamberlain RC, Pelletier JH, Blanchard S, Hornik CP, Hill KD, Campbell MJ. Evaluating Appropriate Use of Pediatric Echocardiograms for Chest Pain in Outpatient Clinics. J Am Soc Echocardiogr 2017; 30:708-713. [DOI: 10.1016/j.echo.2017.03.008] [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: 09/29/2016] [Indexed: 10/19/2022]
|
7
|
Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KWD, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice. Am J Cardiol 2016; 118:1545-1551. [PMID: 27639687 DOI: 10.1016/j.amjcard.2016.08.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ritu Sachdeva
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
| | - Pamela S Douglas
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael S Kelleman
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Leo Lopez
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Kenan W D Stern
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, New York, New York
| | - Benjamin W Eidem
- Division of Pediatric Cardiology, Department of Pediatrics, Mayo Clinic Rochester, Rochester, Minnesota
| | - Oscar J Benavidez
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Welch
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Robert M Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Wyman W Lai
- Division of Pediatric Cardiology, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, New York
| |
Collapse
|
8
|
Rose-Felker K, Kelleman MS, Campbell RM, Oster ME, Sachdeva R. Appropriate Use and Clinical Impact of Echocardiographic “Evaluation of Murmur” in Pediatric Patients. CONGENIT HEART DIS 2016; 11:721-726. [DOI: 10.1111/chd.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Michael S. Kelleman
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Robert M. Campbell
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Matthew E. Oster
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Ritu Sachdeva
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| |
Collapse
|
9
|
Sachdeva R, Douglas PS. Quality Improvement Interventions to Improve Appropriateness of Imaging Studies. Circ Cardiovasc Qual Outcomes 2016; 9:2-4. [DOI: 10.1161/circoutcomes.115.002510] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ritu Sachdeva
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.)
| | - Pamela S. Douglas
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.)
| |
Collapse
|