Escalating medical costs threaten our national provision of medical services. As a nation, we spend a far larger percentage of our gross national product on medical care compared with other industrialized nations, yet our satisfaction ratings and performance measures are not as high. Excessive and inappropriate testing may contribute to these findings.

In March 2005, the Medicare Payment Advisory Commission reported to Congress that between 1999 and 2002, the annual rate of growth for echocardiography was disproportionately high at 11.8%, compared with 5.2% for all services provided by Medicare. This has led to concern about the overutilization of echocardiography and has put it in the spotlight for both policy makers and third-party payers. Continuing growth in medical expenditures at rates far exceeding those of inflation will not be sustainable in the long term.

In an attempt “to respond to the need for the rational use of imaging services in the delivery of high quality care”, the American College of Cardiology Foundation (ACCF) developed appropriateness criteria for the use of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). These criteria were not meant to be inclusive of all potential indications for echocardiography but included 59 clinical scenarios believed to be most commonly encountered. These were then rated by technical panel members as appropriate, inappropriate, or uncertain, on the basis of the clinical judgment and opinion of the panel members, as well as on the available supporting clinical evidence, and scores were averaged.

There has been considerable interest regarding the application of these criteria in clinical practice. Prior efforts to apply these criteria to TTE and TEE have met with varying success. Our large patient-oriented academic medical center is unique in its number of specialists and includes >150 cardiologists. The purposes of this study were to assess the feasibility and reproducibility of application of the ACCF appropriateness criteria in our particular practice; to determine the percentages of studies that are appropriate, inappropriate, and uncertain, in inpatient and outpatient practices, for both TTE and TEE; and to identify any important indications not included in the criteria or clarifications to these criteria that are needed.

Methods

Several assumptions were necessary to complete the project. First, because many indications in the criteria are not mutually exclusive, we considered the criteria tables in a specified order to reflect clinical decision making and appropriate test utilization. For example, a patient undergoing TTE for the evaluation of mitral regurgitation and worsening symptoms of heart failure could be classified as either criterion 27 (“re-evaluation of native valvular regurgitation in patients with a change in clinical status”) or 43 (“re-evaluation of known heart failure [systolic or diastolic] to guide therapy in a patient with a change in clinical status”). The sequential order for TTE was the same as published in the ACCF appropriateness criteria ( Tables 1-7 ). In addition, criterion 53 (“guidance during percutaneous noncoronary cardiac interventions including but not limited to septal ablation in patients with hypertrophic cardiomyopathy, mitral valvuloplasty, PFO [patent foramen ovale]/ASD [atrial septal defect] closure, radiofrequency ablation”) was considered to include TTE performed for guidance during right ventricular biopsy or pacemaker lead placement. The criteria for the use of TEE were reordered as listed in Table 1 , and patients were classified by the first criterion they matched. Thus, the above patient, if referred for TEE, would be classified according to criterion 27. An exception to this was the application of criterion 1 (“symptoms potentially due to suspected cardiac etiology, including but not limited to dyspnea, shortness of breath, lightheadedness, syncope, TIA [transient ischemic attack], cerebrovascular events”).

Table 1

Prioritization of tables from ACCF appropriateness criteria for TEE

Sequential order in which tables were considered	Published appropriateness table number	Indication classification
1	7	Use of transesophageal echocardiogram (TEE)
2	3	Evaluation of valvular function
3	4	Evaluation of intracardiac and extracardiac structures and chambers
4	1	General evaluation of structure and function
5	2	Cardiovascular evaluation in an acute setting
6	5	Evaluation of aortic disease
7	6	Evaluation of hypertension, heart failure, or cardiomyopathy

 

Table 2

Patient characteristics (n = 529)

Characteristic	n (%)
Female sex	223 (42.2)
Murmur	178 (33.6)
Valvular disease	149 (28.2)
Peripheral arterial disease	42 (7.9)
Stroke/transient ischemic attack	95 (18.0)
Congestive heart failure	139 (26.3)
Coronary artery disease	124 (23.4)
Atrial fibrillation	174 (32.9)
Pulmonary disease	97 (18.30
Obstructive sleep apnea	58 (11.0)
Pacemaker/implantable cardioverter-defibrillator	64 (12.1)
Diabetes mellitus	118 (22.3)
Hypertension	300 (56.7)
Hyperlipidemia	264 (50.0)
Active or prior smoker ∗	288 (55.3)
Myocardial infarction	65 (12.3)
Prior coronary revascularization	91 (17.2)
Chest pain	103 (19.5)
Shortness of breath	194 (36.7)
Abnormal electrocardiogram	393 (74.3)

 

∗ Smoking status was not available for 8 patients.

Table 3

Classification of TTE patients, according to tables of indications in ACCF appropriateness criteria

Published appropriateness table number	Indication classification	Setting	Appropriate	Uncertain	Inappropriate	Total	P ∗
1	General evaluation of structure and function	Inpatient	47	0	0	47	.04
		Outpatient	64	0	6	70
2	Cardiovascular evaluation in an acute setting	Inpatient	27	0	0	27	.00
		Outpatient	0	0	0	0
3	Evaluation of valvular function	Inpatient	24	0	0	24	.01
		Outpatient	29	0	9	38
4	Evaluation of intracardiac and extracardiac structures and chambers	Inpatient	8	0	0	8	.00
		Outpatient	11	0	0	11
5	Evaluation of aortic disease	Inpatient	0	0	0	0	.00
		Outpatient	0	0	0	0
6	Evaluation of hypertension, heart failure, or cardiomyopathy	Inpatient	22	0	0	22	.07
		Outpatient	38	0	6	44
7	Use of transesophageal echocardiogram (TEE)	Inpatient	8	0	0	8	.00
		Outpatient	0	0	0	0
Total			278	0	21	299

 

∗ Inpatient versus outpatient echocardiography.

Table 4

Classification of TEE patients according to tables of indications in ACCF appropriateness criteria

Published appropriateness table number	Indication classification	Setting	Appropriate	Uncertain	Inappropriate	Total	P ∗
1	General evaluation of structure and function	Inpatient	3	0	0	3	.00
		Outpatient	7	0	0	7
2	Cardiovascular evaluation in an acute setting	Inpatient	2	0	0	2	.00
		Outpatient	1	0	0	1
3	Evaluation of valvular function	Inpatient	8	0	1	9	.78
		Outpatient	12	0	1	13
4	Evaluation of intracardiac and extracardiac structures and chambers	Inpatient	39	0	0	39	.00
		Outpatient	36	0	0	36
5	Evaluation of aortic disease	Inpatient	0	0	0	0	.00
		Outpatient	0	0	0	0
6	Evaluation of hypertension, heart failure, or cardiomyopathy	Inpatient	1	0	0	1	.00
		Outpatient	1	0	0	1
7	Use of transesophageal echocardiogram (TEE)	Inpatient	42	0	0	42	.30
		Outpatient	39	1	0	40
Total			191	1	2	194

 

∗ Inpatient versus outpatient echocardiography.

Table 5

Inappropriate TTE and TEE by ACCF appropriateness table and specific indication

Appropriateness table	Criterion	Description	TEE	TTE	Total (%)
1 (General evaluation of structure and function)	5	Patients who have isolated APC or PVC without other evidence of heart disease	0	3	3 (13.0)
	7	Evaluation of LV function with prior ventricular function evaluation within the past year with normal function (such as prior echocardiogram, LV gram, SPECT, cardiac MRI) in patients in whom there has been no change in clinical status	0	3	3 (13.0)
3 (Evaluation of valvular function)	21	Routine (yearly) re-evaluation of an asymptomatic patient with mild native AS or mild-moderate native MS and no change in clinical status	0	3	3 (13.0)
	29	Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status	0	5	5 (21.7)
	32	Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of bacteremia or new murmur	2	1	3 (13.0)
6 (Evaluation of hypertension, heart failure, or cardiomyopathy)	40	Re-evaluation of a patient with known hypertensive heart disease without a change in clinical status	0	2	2 (8.7)
	42	Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status	0	4	4 (17.4)
Total			2	21	23 (100)

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