As the cost and complexity of healthcare in the United States have increased, the overuse of resources has become a considerable concern. Unnecessary or low value echocardiographic examinations are just one of the many areas that requires attention and was addressed by the ASE in an Appropriate Use Criteria (AUC) publication in 2011. The AUC is available online at www.asecho.org/wordpress/wp-content/uploads/2013/05/Appropriate-Use-Criteria-for-Echo_2011.pdf .
In an effort to further support the rational use of echocardiography, the ASE partnered with the American Board of Internal Medicine (ABIM) Foundation in its Choosing Wisely ® campaign. The goal of Choosing Wisely ® is to promote conversations between physicians and patients that allows patients to choose care that is supported by evidence, not duplicative of other tests already performed, free from harm and medically necessary. In line with this goal, the ASE released a list of 5 recommendations for physicians and patients pertinent to the field of echocardiography (the list can be found at www.choosingwisely.org/doctor-patient-lists/american-society-of-echocardiography/ ). Two of the items on the list have direct implications for the perioperative use of echocardiography.
The first suggests that physicians “Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.” Although evidence exists indicating patients with a low ejection fraction are at an increased risk of perioperative cardiac complications, the marginal utility of quantifiying systolic function is small when compared to assessing a patient’s symptoms related to heart disease. Furthermore, the positive predictive value of a low ejection fraction is low. Rather than using preoperative echocardiography to screen for poor systolic function, echocardiography should be reserved to clarify risk in symptomatic patients.
The second recommendation is to “Avoid using stress echocardiograms on asymptomatic patients who meet low-risk scoring criteria for coronary disease.” Specific to the perioperative setting, stress echocardiograms should be avoided as a tool to measure cardiovascular risk. Much of the data supporting use of stress testing in the preoperative period is in high-risk patients with a low MET equivalent (< 4 mets) undergoing vascular surgery. Conversely, no evidence exists supporting the use of stress echocardiograms in patients who can reach a MET equivalent of 7–10 mets as the incidence of cardiovascular complications is low in this patient population. Thus, routine use of stress echocardiograms should not be performed in these patients as part of a preoperative evaluation.
In each of these scenarios, clinicians are often ordering echocardiographic examinations to ensure that complete preoperative evaluations have been performed. Motivation to order unnecessary tests may arise from fears of malpractice, case cancellations or delays, or simply checking off a box on the preoperative evaluation protocol. However, an echocardiographic examination is not a prerequisite for a complete preoperative evaluation, and despite the potential that more knowledge is better, one must consider whether the added knowledge of an echocardiographic examination will change the perioperative management of a patient. Clearly many clinical scenarios occur where critical decision-making is paramount when choosing an appropriate test or intervention, but the scenarios discussed above are two very specific indications where echocardiographic examinations are commonly overused or misused. Additional consumer information was made available by ASE and Consumer Reports, a Choosing Wisely partner, in an article entitled “Echocardiogram Before Surgery: When you need it—and when you don’t” ( www.choosingwisely.org/doctor-patient-lists/echocardiogram-before-surgery/ ).
To aid physicians in determining if an echocardiographic examination appropriate, the ASE has developed a free app that can be downloaded to a smartphone or tablet titled “Echo AUC.” This app provides a resource to help physicians make wise decisions when it comes to evidence-based recommendations for the use of echocardiography in all areas. Supporting initiatives like Choosing Wisely ® will not only aid in reducing overuse, but will ultimately result in enhanced patient care.