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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Quartermain MD, Hill KD, Goldberg DJ, Jacobs JP, Jacobs ML, Pasquali SK, Verghese GR, Wallace AS, Ungerleider RM. Prenatal Diagnosis Influences Preoperative Status in Neonates with Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Pediatr Cardiol 2019; 40:489-496. [PMID: 30341588 DOI: 10.1007/s00246-018-1995-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/26/2018] [Indexed: 11/30/2022]
Abstract
The early postnatal course for a newborn with critical congenital heart disease (CHD) can be negatively impacted if diagnosis is delayed. Despite this, there continues to be inconsistent evidence regarding potential benefits associated with prenatal diagnosis (PND) in neonates who undergo cardiac surgery. The objective of this study was to better define the impact of a PND on pre-operative morbidity by utilizing a large clinical database. Neonates (< 30 days) undergoing heart surgery from 2010 to 2014 and entered in the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) were included. Multivariable logistic regression was used to evaluate the association between PND and a composite measure including nine major pre-operative risk factors. Co-variates were included to adjust for important patient characteristics (e.g., weight-for-age z-score, genetic syndromes, prematurity), case complexity, and center effects. Centers and patients with excess missing data for relevant co-variates were excluded. Included were 12,899 neonates undergoing surgery at 112 centers. Major pre-operative risk factors were present in 34% overall. By univariate analysis, PND was associated with a lower overall prevalence of major pre-operative risk factors. After adjusting for potential confounders, major pre-operative risk factors were less prevalent among neonates with PND compared to neonates without PND (adjusted OR 0.62, 95% CI 0.57-0.68, p < 0.001). A sensitivity analysis excluding neonates with genetic syndromes, non-cardiac anatomic abnormalities, and prematurity demonstrated similar findings (adjusted OR 0.55, 95% CI 0.49-0.61, p < 0.0001). Among neonates with CHD, prenatal diagnosis is associated with significantly lower rates of pre-operative risk factors for cardiac surgery. Further studies are needed to define association of these pre-operative benefits of a PND with longer term clinical outcomes.
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Affiliation(s)
- Michael D Quartermain
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. .,Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Civic Center Blvd. Echo Lab, 3rd Floor Main Bldg, Suite 3NW110, Philadelphia, PA, 19104, USA.
| | - Kevin D Hill
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - David J Goldberg
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jeffrey P Jacobs
- Department of Surgery, All Children's Hospital and Johns Hopkins University, Saint Petersburg, FL, USA
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - George R Verghese
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Stern KWD, White MT, Verghese GR, Del Nido PJ, Geva T. Intraoperative Echocardiography for Congenital Aortic Valve Repair: Predictors of Early Reoperation. Ann Thorac Surg 2015; 100:678-85. [PMID: 26138765 DOI: 10.1016/j.athoracsur.2015.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/26/2015] [Accepted: 05/01/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND We sought to identify transesophageal echocardiography (TEE) predictors of early reoperation for recurrent aortic regurgitation (AR) after cardiopulmonary bypass (CPB) in patients undergoing repair for congenital aortic valve disease. METHODS We analyzed post-CPB TEEs in patients with congenital aortic valve disease undergoing repair for predominant AR. Case patients underwent reoperation for recurrent AR within 2 years, whereas control patients were free from reoperation for more than 3 years. RESULTS Case patients (n = 22; median time to reoperation 0.3 years) and control patients (n = 22; median freedom from reoperation ≥4.4 years) were similar for demographic characteristics, aortic dimensions, and preoperative AR grade. Among post-CPB TEE variables, univariate logistic regression analysis identified shorter coaptation height (odds ratio [OR] for 1-mm increase 0.72, 95% confidence interval [CI]: 0.54 to 0.95; p = 0.02), decreased ratio of coaptation height to annulus diameter (OR for a 5% decrease 1.37, 95% CI: 1.06 to 1.77; p = 0.02), and increased percentage difference (%diff) between longest and shortest coaptation lengths in a short-axis view (OR for 10% increase 1.84, 95% CI: 1.15 to 2.92; p = 0.01) as risk factors for early reoperation for recurrent AR. Multivariable analysis identified %diff in short-axis coaptation lengths as the strongest post-CPB TEE predictor (area under receiver operator curve = 0.743). The sensitivity and specificity of a %diff of 50% were 0.45 and 0.91, whereas a %diff of 30% had a sensitivity of 0.75 and specificity of 0.67. CONCLUSIONS Coaptation asymmetry, measured as increased %diff in short-axis coaptation lengths on post-CPB TEE, is associated with early reoperation for recurrent AR after congenital valve repair.
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Affiliation(s)
- Kenan W D Stern
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Matthew T White
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - George R Verghese
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Verghese GR, Friedman KG, Rathod RH, Meiri A, Saleeb SF, Graham DA, Geggel RL, Fulton DR. Resource Utilization Reduction for Evaluation of Chest Pain in Pediatrics Using a Novel Standardized Clinical Assessment and Management Plan (SCAMP). J Am Heart Assoc 2012; 1:jah39. [PMID: 23130120 PMCID: PMC3487367 DOI: 10.1161/jaha.111.000349] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 01/26/2012] [Indexed: 11/16/2022]
Abstract
Background Chest pain is a common reason for referral to pediatric cardiologists. Although pediatric chest pain is rarely attributable to serious cardiac pathology, extensive and costly evaluation is often performed. We have implemented a standardized approach to pediatric chest pain in our pediatric cardiology clinics as part of a broader quality improvement initiative termed Standardized Clinical Assessment and Management Plans (SCAMPs). In this study, we evaluate the impact of a SCAMP for chest pain on practice variation and resource utilization. Methods and Results We compared demographic variables, clinical characteristics, and cardiac testing in a historical cohort (n=406) of patients presenting to our outpatient division for initial evaluation of chest pain in the most recent pre-SCAMP calendar year (2009) to patients enrolled in the chest pain SCAMP (n=364). Demographic variables including age at presentation, sex, and clinical characteristics were similar between groups. Adherence to the SCAMP algorithm for echocardiography was 84%. Practice variation decreased significantly after implementation of the SCAMP (P<0.001). The number of exercise stress tests obtained was significantly lower in the SCAMP-enrolled patients compared with the historic cohort (∼3% of patients versus 29%, respectively; P<0.001). Similarly, there was a 66% decrease in utilization of Holter monitors and 75% decrease in the use of long-term event monitors after implementation of the chest pain SCAMP (P=0.003 and P<0.001, respectively). The number of echocardiograms obtained was similar between groups. Conclusions Implementation of a SCAMP for evaluation of pediatric chest pain has lead to a decrease in practice variation and resource utilization. (J Am Heart Assoc. 2012;1:jah3-e000349 doi: 10.1161/JAHA.111.000349.)
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Affiliation(s)
- George R Verghese
- Department of Cardiology, Children's Hospital Boston and the Department of Pediatrics, Harvard Medical School Boston, MA
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Verghese GR, McElhinney DB, Strauss KJ, Bergersen L. Characterization of radiation exposure and effect of a radiation monitoring policy in a large volume pediatric cardiac catheterization lab. Catheter Cardiovasc Interv 2011; 79:294-301. [PMID: 21523897 DOI: 10.1002/ccd.23118] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 03/07/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study aimed to characterize radiation dose during cardiac catheterization in congenital heart disease and to assess changes in dose after the introduction of a radiation monitoring policy. BACKGROUND Minimizing radiation exposure is an important patient safety initiative and relatively few data are available characterizing radiation dose for the broad spectrum of congenital cardiac catheter-based interventions. METHODS Radiation dose data were reviewed on all cases since 7/1/05 at a single large center. Procedures were classified according to 20 common case types then subdivided into five age categories. Groups with <20 cases were excluded. Radiation dose was estimated by cumulative air KERMA (mGy) and DAP (dose area product, μGym(2)) which were reported as median and interquartile range (IQR). We also examined differences in radiation dose before and after the implementation of a radiation policy. RESULTS Between 7/1/05 and 12/10/08, 3,365 cases were identified for inclusion. Radiation dose increased with age and procedural complexity. Patients were characterized into low, medium, and high dose categories relative to each other. "Low" dose cases included isolated pulmonary or aortic valvotomy, pre-Fontan assessment, and ASD closure. "High" dose cases involved multiple procedures in pulmonary arteries or veins. After introduction of a radiation policy, there was a significant decrease in radiation dose across a variety of case types, particularly among infants and young children. CONCLUSIONS Radiation dose in congenital cardiac catheterization varies by age and procedure type. A radiation monitoring and notification policy may have contributed to reduced radiation dose.
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Affiliation(s)
- George R Verghese
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA
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Verghese GR, McElhinney DB, Bergersen L. CHARACTERIZATION OF HIGH LEVELS OF RADIATION EXPOSURE IN A LARGE VOLUME PEDIATRIC CARDIAC CATHETERIZATION LAB. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61999-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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