Appropriate Use Criteria for paediatric echocardiography in an outpatient practice: a validation study (original) (raw)
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The Journal of Pediatrics, 2019
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" (
Journal of the American College of Cardiology, 2014
representative. yAmerican Academy of Pediatrics representative. zHeart Rhythm Society representative. xAmerican Society of Echocardiography representative. jjSociety of Pediatric Echocardiography representative. {Society for Cardiovascular Magnetic Resonance representative. #Society of Cardiovascular Computed Tomography representative. **Health Plan representative. yyAmerican Heart Association representative. zzSociety for Cardiovascular Angiography and Interventions representative. This document was approved by the American College of Cardiology Board of Trustees in June 2014.
Trends in Outpatient Transthoracic Echocardiography: Impact of Appropriateness Criteria Publication
The American Journal of Medicine, 2011
BACKGROUND: The impact of the 2007 American College of Cardiology Foundation Transthoracic Echocardiography Appropriateness Criteria on trends in appropriateness is unknown. Therefore, we sought to identify the appropriateness of outpatient transthoracic echocardiography pre-and postpublication of this document. METHODS: The 2007 Appropriateness Criteria were used to classify outpatient echocardiographic studies at an academic medical center during October 2000 and October 2008. The patient's electronic medical record was used to identify echocardiographic indication and appropriateness. RESULTS: From October 2000 to October 2008, there was an 85% increase in outpatient echocardiographic volume. Using the Appropriateness Criteria, there was no significant change in inappropriate referrals (13% and 15%, P ϭ .58). Sixty-five studies (12%) were referred for indications "not addressed" by the document, with an increase (7% to 15%, P ϭ .012) from 2000 to 2008. In a second analysis, incorporating the 2008 Valve Guidelines, an increase was demonstrated in the total number of studies that could be classified, but there was no significant change in the proportion of inappropriate referrals (P ϭ .50). There remained a significant increase (3% to 10%, P ϭ .009) in the proportion of indications "not addressed" by either guideline. CONCLUSION: From October 2000 to October 2008, we experienced a near doubling of outpatient echocardiographic volume, with no significant change in the percent of inappropriate referrals despite interim publication of the Appropriateness Criteria document. In addition, there was an increase in echocardiographic referrals for "not addressed" indications. Future efforts are needed both to refine the Appropriateness Criteria to include unaddressed indications and to promote its effective implementation.
Journal of the American Society of Echocardiography, 2008
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 ϭ 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 ϭ NS) and clinical utility (60% vs 61%, P ϭ 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 Ͻ .001), and adherence of indication to guidelines was the major determinant of clinical utility at logistic regression analysis (P Ͻ .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.
European Heart Journal - Cardiovascular Imaging, 2013
Appropriateness of use criteria (AUC) for transthoracic echocardiography (TTE) have been developed by American cardiology associations to help avoid unnecessary scans by formalizing indications for imaging. There are 98 indications classified as either appropriate (A), inappropriate (I), or uncertain (U). AUC may allow better targeting of limited resources, but they have not been tested systematically outside the USA. Aim of the study To test AUC in Wales, one of the four countries of the UK. Methods We collected requests for TTE and the corresponding TTE reports from all Welsh hospitals during 1 week in June 2012 and analysed them according to appropriateness, specialty, and location (secondary vs. tertiary services) of the referring physician. Results We analysed 1070 pairs of echocardiography requests and TTE reports from 14 hospitals [mean age 66.5 (16.1) years; 579 (51%) M]: A-922 (86%); I-115 (11%), and U-33 (3%); 287 (25%) studies were from two tertiary centres and 338 (29.5%) were of inpatients. Main indications were the evaluation of: cardiac structure and function (489, 45.7%), valvular function (267, 25%), and hypertension, heart failure, or cardiomyopathy (149, 13.9%). In-patient requests (main indication-'initial evaluation of left ventricle ejection fraction post acute coronary syndrome'-44 studies, 13.7%) were more often appropriate than outpatients (main indication-'symptoms/conditions potentially related to suspected cardiac aetiology'-142 studies, 19.8%): 94.4 vs. 83.5%, P , 0.05. The most common inappropriate indication was 'initial evaluation for a murmur/click without symptoms/signs of structural heart disease' (29 studies, 2.7%). The proportion of appropriate requests by specialty was 89% for medical, 87% for GPs, 85.3% for cardiologists, 80.8% for surgical, and 60% for cardiac surgeons (P , 0.05 for cardiac surgeons); 47.8% of requests were generated by cardiologists, and abnormalities were detected in 82% of all scans (37% minor findings and 45% major findings), least often in those requested by general practitioners. Conclusion Application of AUC yields results similar to those reported from the USA; 1 in 10 scans could be avoided.
Transtelephonic echocardiography: Successful use in a tertiary pediatric referral center
The Journal of Pediatrics, 1993
Recent advances in computers and telecommunications have made transtelephonic echocardiography practical. Our institution is developing a network of transmissional echocardiographic sites at several hospitals in our referral region. We reviewed our initial experience to determine whether transmissional echocardlographic studies (1) gave an appropriate diagnostic impression compared with subsequent videotape review and (2) led to appropriate cllnlcal management (Le., transfer to a tertiary center or continuation of local care and follow-up). From Aug.1, 1991, to May 31,1992,we evaluated 47 transmissional studies (diagnoses: 24 normal, 8 patent ductus arteriosus, 6 ventricular septal defect, 2 pulmonary stenosis, 1 ventricular septal defect with interrupted aortic arch, and 6 miscellaneous). Of 47 studies, 39 (83%) were thought to give accurate diagnostic impressions compared with videotape review. Most inaccuracies were due to the selection and transmission of inconclusive information in an otherwise accurate diagnostic study. Only 1 (2%) of 47 studies resulted in an inappropriate clinical decision; a patient's transfer for treatment of a patent ductus arteriosus was delayed 1day because of an inconclusive transmissional study. We conclude that transmissional echocardiography is useful in the management of pediatric patients with suspected heart disease in a regional referral setting.
Heart, 1996
Objectives-To evaluate the changing role of an open-access consultant-led paediatric echocardiography service for the detection and assessment of cardiac disease in children. Design-A retrospective analysis comparing two patient groups undergoing echocardiography over two corresponding six month periods in 1989 and 1994. Setting-A tertiary referral centre. Main outcome measures-Patient demographics, indication for echocardiogram, source of referral and findings on scan in new referrals, subsequent foilow up arrangements.
Journal of Clinical & Experimental Cardiology, 2010
Introduction: Echocardiography is the modality of choice for investigation of suspected congenital or acquired heart disease. It may be used as part of the screening process for suspected heart disease in childhood after the incidental fi nding of a murmur, even if this is deemed to be an innocent murmur by the referring clinician. However some studies have shown that parents may misunderstand the implications of a normal test and may persistently restrict their child's activity even after a normal echocardiogram. The second part of this study prospectively audited echocardiography requests for non-elective (urgent) echocardiograms, in the setting of a regional hospital that serves an entire captive island population for the period 2007. An analysis of parental understanding of a normal echocardiogram was also carried out. Methods: All normal and all urgent echocardiograms were prospectively collected for the 2007 Parents were administered a telephone questionnaire with regard to their understanding of a normal echocardiogram, after one month. Information collected also included age of patient, delay from request to actual procedure, actual indication and echocardiographic outcome (diagnosis). Results: 88 non-elective echocardiograms were performed with a bimodal age distribution ranging from 1 hour to 50 years. The majority were infants. 6 patients were aged over 14 years. The delay to the actual performance of the echocardiogram ranged from 2 hours to 20 days, with a mean of 2.8 days and a median of 1 day. The outcome was completely normal in 35 individuals, physiological for age in 14 individuals (total normal of 49-55%) and abnormal in 39. 89 normal echocardiograms were included. 79 parents stated that they were fully satisfi ed with the explanation and implications of a normal echocardiogram and 10 were almost fully satisfi ed. No signifi cant differences could be found between these two groups. A hard copy was more likely to reassure the parents, but not at a statistically signifi cant level. Only 77 had a full explanation with regard to the implications of an innocent murmur with echocardiographic confi rmation but this too did not affect parental reassurance. Discussion: 88 non-elective echocardiograms accounted for 10% of the total paediatric echocardiogram referrals for the period 2007, with a signifi cant pickup rate for pathological lesions. For normal echocardiography examinations, this study confi rms that parents are satisfi ed with an explanation of the implications of a normal echocardiogram. Our service can be improved by providing a full explanation to all parents and by adopting the policy of giving a hard copy of the normal report to all parents. This study prospectively analysed two facets of paediatric echocardiography: 1. An audit of requests for the first two groups as above, that is, non-elective (urgent) echocardiograms, in the setting of a regional hospital that serves an entire captive island population [6]. 2. This study also prospectively analysed the degree of parental understanding of a normal echocardiogram. Methods Audit of urgent echocardiography referrals Data from all individuals referred for echocardiogram to the only