Abstract
Echocardiography is an important tool in the diagnosis and management of cardiovascular disease. However, there has been concern in recent years regarding the rapid growth of echocardiography utilization. The American College of Cardiology Foundation (ACCF), along with other subspecialty societies, developed Appropriate Use Criteria (AUC) in an effort to promote more effective utilization of diagnostic testing and procedures in cardiovascular medicine, and echocardiography has been a focus of the AUC. AUC are distinct from clinical practice guidelines, as AUC delineate clinical scenarios in which ordering a test or procedure may be considered appropriate or less appropriate. Revised and updated AUC for adult echocardiography were published in 2011. One of the first uses of the AUC for echocardiography was to characterize practice patterns and determine appropriateness rates in clinical practice. Moving beyond a description of ordering patterns in clinical practice, educational intervention studies have been designed which incorporate AUC into the process of educating ordering clinicians. Several studies indicate that it is feasible to teach clinicians about appropriate use and that providing feedback about ordering behavior may improve utilization. The importance and role of feedback in AUC-based educational efforts is supported by the results of these studies. The optimal approach to incorporate AUC into patient selection remains to be determined, and it should be emphasized that clinical judgment remains important and is not to be replaced by criteria. Adherence to AUC and the subsequent impact on clinical outcomes, although difficult to study, is a critical area in need of further investigation.
Keywords
appropriate use, echocardiography, education, quality improvement, utilization
Introduction
Echocardiography is an important tool in the diagnosis and management of cardiovascular disease. The detailed cardiac structural and functional information that echocardiography provides, coupled with its portability and lack of ionizing radiation, has established this imaging modality as a critical tool in the care of patients with known or suspected cardiovascular disease. However, there has been concern in recent years regarding the rapid growth of echocardiography utilization, which was estimated at 6%–8% per year in the early 2000s. Although the widespread use of echocardiography has been in keeping with the overall growth in cardiac imaging services, geographic variation and concerns regarding appropriate use have helped stimulate a drive for improved utilization of clinical echocardiography services.
Introduction
Echocardiography is an important tool in the diagnosis and management of cardiovascular disease. The detailed cardiac structural and functional information that echocardiography provides, coupled with its portability and lack of ionizing radiation, has established this imaging modality as a critical tool in the care of patients with known or suspected cardiovascular disease. However, there has been concern in recent years regarding the rapid growth of echocardiography utilization, which was estimated at 6%–8% per year in the early 2000s. Although the widespread use of echocardiography has been in keeping with the overall growth in cardiac imaging services, geographic variation and concerns regarding appropriate use have helped stimulate a drive for improved utilization of clinical echocardiography services.
Development of Appropriate use Criteria
The American College of Cardiology Foundation (ACCF), along with other subspecialty societies, developed Appropriate Use Criteria (AUC) in an effort to promote more effective utilization of diagnostic testing and procedures in cardiovascular medicine, and echocardiography has been a focus of the AUC. The AUC were developed primarily out of concern regarding an increase in the use of noninvasive cardiac imaging services and Medicare spending between 1995 and 2006, and the ACCF published its first AUC document in 2005. AUC are distinct from clinical practice guidelines, as guidelines are intended to inform clinicians when a diagnostic test or procedure should or should not be performed. In contrast, AUC delineate clinical scenarios in which ordering a test or procedure may be considered appropriate or less appropriate.
Initial AUC for transthoracic (TTE) and transesophageal (TEE) echocardiography were published in 2007 and stress echocardiography (SE) AUC were released in 2008. The AUC are based on a number of common clinical scenarios in which echocardiography is most often used. Revised and updated AUC covering adult TTE, TEE, and SE were published in 2011; however, this document does not address the use of perioperative TEE. AUC for initial outpatient pediatric echocardiography were published in 2014. The 2011 revised AUC for adult echocardiography incorporated data and recommendations provided by interval clinical data and standards documents published after the release of the initial AUC in 2007 and 2008. Additionally, the revised AUC clarified areas in which omissions or lack of clarity existed in the original criteria. The approach for the revised 2011 AUC for adult echocardiography was to create five broad types of clinical scenarios regarding the possible use of echocardiography: (1) for initial diagnosis; (2) to guide therapy or management, regardless of symptom status; (3) to evaluate a change in clinical status or cardiac exam; (4) for early follow-up without change in clinical status; and (5) for late follow-up without change in clinical status. Certain specific clinical scenarios were addressed with additional focused indications. The evaluation of heart failure provides an example of the main types of clinical scenarios found in the AUC for TTE ( Fig. 47.1 ).
The scenarios are rated by a panel with a broad array of expertise (i.e., including not only echocardiographers) to evaluate the “appropriateness” of echocardiography in each situation. AUC ratings are created by applying the validated, prospectively based modified RAND (Research and Development) appropriateness method. Briefly, this process involves: (1) the development of a list of clinical indications, assumptions, and definitions by a writing group; (2) a review of indications and feedback from a review panel; and (3) two rounds of indication ratings by a rating panel (first round, no interaction among panel members; second round, panel interaction) and determination of a composite appropriate use score ( Fig. 47.2 ).
An appropriate imaging study is defined as “one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.” Ratings are made on a scale of 1–9, in which a score of 9 indicates highly appropriate use of testing. Using the iterative modified Delphi exercise process describedpreviously, a final rating score is established for each indication, and grouped as A, a score of 7–9, indicating an appropriate test for the specific indication (the test is generally acceptable and is a reasonable approach for the indication); U, a score of 4–6, indicating uncertainty for the specific indication (the test may be generally acceptable and may be a reasonable approach for the indication); and I, a score of 1–3, indicating an inappropriate test for that indication (the test is not generally acceptable and is not a reasonable approach for the indication).
The AUC methodology has subsequently evolved over time. Importantly, the terminology used to describe the three appropriateness categories has changed. As mentioned previously, studies for specific clinical indications were initially divided into appropriate, uncertain, or inappropriate categories. The revised terminology specifies “appropriate care,” “may be appropriate care,” and “rarely appropriate care.” It is therefore more explicitly recognized that a rarely appropriate study may be correct for a specific patient at a specific time; therefore, the goal for rarely appropriate studies is not necessarily zero.
Application of Appropriate Use Criteria
One of the first uses of the AUC for echocardiography was to characterize practice patterns and determine appropriateness rates in clinical practice. A number of studies evaluated the 2007 AUC for TTE in various practice settings, including academic medical centers, Veterans Affairs (VA) hospitals, and community settings. Several common themes emerged, namely that 10%–15% of TTEs could not be classified by the AUC; however, of those classified, the majority (∼90%) were deemed appropriate. The influence of practice location was noted, as the rate of inappropriate studies was higher in the outpatient (vs. inpatient) environment. Subsequent studies at academic medical centers utilizing the 2011 AUC showed that the updated AUC were able to classify the vast majority of TTEs and filled virtually all of the gaps in the initial AUC. Another finding was that with the improved classification of TTEs with the 2011 AUC, it appeared that the appropriate rate of TTEs was not as high as initially thought (e.g., previously unclassified studies were more likely to be categorized as rarely appropriate). This indicated that there may be more opportunities for practice improvement and improved utilization than initially realized. Studies of TEE utilization in general show higher appropriate rates, possibly due to the more invasive nature of the procedure and the associated case review and need for informed consent. Studies of SE show lower appropriate rates, which is consistent with studies of other forms of stress testing. Furthermore, recent analyses indicate that AUC have relevance beyond the United States, with a recent study in the United Kingdom reporting similar rarely appropriate rates for TTE.
In addition to characterizing the percentage of appropriate and rarely appropriate studies, the analyses of practice patterns identified a relatively small number of specific indications that constituted the most common rarely appropriate indications, which varied based on practice setting (outpatient vs. inpatient) ( Box 47.1 ). In the outpatient setting, the most common rarely appropriate TTEs are mainly “surveillance” studies, referring to repeat studies in patients with known cardiovascular disease, but no change in clinical status or physical examination. In this context, if echocardiograms are ordered prior to prespecified time intervals (e.g., within 3 years in the case of mild valvular disease, and no change in clinical status or examination) they are classified as rarely appropriate.
Outpatient
- •
Routine surveillance (<3 year) of mild valvular stenosis without change in clinical status or cardiac examination
- •
Routine reevaluation for surveillance of known ascending aortic dilation or history of aortic dissection without change in clinical status or cardiac examination, and findings will not change management or therapy
- •
Routine evaluation of systemic hypertension without symptoms or signs of hypertensive heart disease
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Evaluation of left ventricular function with previous ventricular function evaluation showing normal function in patients without change in clinical status or cardiac examination
- •
Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease
Inpatient
- •
Transient fever without evidence of bacteremia or a new murmur
- •
Transient bacteremia with a pathogen not typically associated with infective endocarditis and/or a documented nonendovascular source of infection
- •
Lightheadedness/presyncope without other signs/symptoms of cardiac disease
- •
Suspected pulmonary embolism in order to establish diagnosis
Moving beyond a description of ordering patterns in clinical practice, educational intervention studies have been designed, which incorporate AUC into the process of educating ordering clinicians. The aim of such studies is to reduce the number of rarely appropriate TTEs. The first study was conducted on the inpatient medical service of an academic medical center. In this time-series analysis, an educational intervention consisting of a didactic lecture, a pocket card applying the AUC to common clinical scenarios, and twice-monthly feedback emails of ordering behavior resulted in a significant reduction in inappropriate TTEs, and a significant increase in appropriate TTEs. This study was limited by the fact that it was conducted in the inpatient environment and lacked a randomized study design. A subsequent randomized controlled study attempted to address these limitations by utilizing a similar AUC-based educational intervention in an outpatient cardiology environment. This study was limited to physicians-in-training, with a study population consisting of cardiovascular medicine fellows. Nonetheless, the proportion of rarely appropriate TTEs was significantly lower in the intervention group than in the control group, and the proportion of appropriate TTEs ordered by the intervention group was significantly higher. These studies indicate that it is feasible to teach clinicians about appropriate use, and that providing feedback about ordering behavior may improve utilization. Additionally, it appears that knowledge of local practice patterns and “targeting” the educational intervention toward the most common rarely appropriate indications for TTE may aid in creating a successful intervention.
Despite the encouraging results of the educational intervention studies aimed at TTE ordering, it should be emphasized that attempts to utilize AUC to improve utilization of other cardiovascular imaging modalities (e.g., single-photon emission computed tomography [SPECT]) have been met with limited success ( Table 47.1 ). Similarly, a study of SE showed that educating the ordering providers failed to reduce the rate of rarely appropriate studies. Attempting to explain the variability in the effectiveness of educational interventions, it is important to note that the “successful” TTE studies used active feedback as a component of the intervention, whereas the SPECT and SE studies did not. The importance and role of feedback in AUC-based educational efforts is supported by the results of another study of TTE and SPECT in a large multisite cardiovascular practice over a wide geographic area. Another component of an education-based quality improvement initiative that may enhance success in improving utilization is the threat of loss of reimbursement, as documented in a study of coronary computed tomographic angiography (CTA). It therefore appears that AUC-based interventions that focus on feedback and financial implications may be most effective. The available literature also suggest that it may be more difficult to improve the utilization of stress testing (SPECT or SE) compared to resting examinations (TTE or CTA).
| First Author | Imaging Modality | Randomized Trial (Y/N) | Decrease in Rarely Appropriate (Y/N) | Pre- Versus Post-Rarely Appropriate (%) | Feedback Utilized (Y/N) |
|---|---|---|---|---|---|
| Bhatia | TTE | N | Y | 13 vs. 5 | Y |
| Bhatia | TTE | Y | Y | 13 vs. 34 a | Y |
| Gibbons | SPECT | N | N | 14.4 vs. 11.7 | N |
| Willens | SE | N | N | 31.5 vs. 32.4 | N |
| Johnson | TTE SPECT | N | Y Y | 18.5 vs. 6.9 20.5 vs. 11.1 | Y Y |
| Chinnaiyan | CTA | N | Y | 14.6 vs. 5.8 | Y |
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