Background
The appropriateness use criteria (AUC) for the performance of transthoracic echocardiography were recently revised. The aims of this study were to evaluate the 2011 AUC for echocardiography for their ability to categorize indications not addressed by the older AUC and to identify trends in ordering unclassified and inappropriate studies when applying the new AUC.
Methods
We reviewed 384 consecutive adult transthoracic echocardiographic studies performed at a tertiary care teaching hospital. The appropriateness of each study was determined applying both the 2007 and the 2011 AUC.
Results
Among the 384 studies evaluated, 212 (55.2%) were performed in men, 261 (67.9%) were inpatient studies, and 186 (48.4%) were ordered by cardiologists. Compared with the older 2007 AUC, applying the new 2011 AUC demonstrated a lower rate of unclassified studies (5.5% vs 12.5%), higher rates of appropriate (92.2% vs 86.7%) and inappropriate (1.8% vs 0.8%) studies, and no significant change in the rate of uncertain studies (0.5% vs 0.0%). Of the 5.5% of studies that continued to be unclassified despite the application of the more extensive 2011 AUC, common indications included preoperative evaluation for non-transplantation surgery in patients with coronary artery disease, postoperative assessment of thoracic aortic surgery in the absence of any clinical change, and reassessment of ventricular function after revascularization in the absence of acute coronary syndromes.
Conclusions
Compared with the 2007 AUC for transthoracic echocardiography, application of the recently revised 2011 criteria leads to a significant decrease in the number of studies that are not classified, demonstrating that the AUC revision was successful in achieving the goal of addressing more clinical indications.
The American College of Cardiology, in collaboration with the American Society of Echocardiography and other national specialty and subspecialty societies, had published appropriate use criteria (AUC) for echocardiography in an effort to guide and promote the appropriate use of this imaging modality. This initiative in reducing rates of overutilization of echocardiography should ultimately optimize health care expenditures, the quality of care, and clinical outcomes. These AUC were recently revised. In this study, we sought to compare the 2011 AUC for the performance of transthoracic echocardiography (TTE) with the older 2007 AUC for their ability to categorize studies performed for indications not addressed by the older AUC, identify indications not addressed by the new AUC that could potentially be addressed in future revisions, and identify trends in ordering unclassified and inappropriate studies when applying the new AUC at a tertiary care teaching institution.
Methods
Study Population and Design
We reviewed 384 consecutive adult transthoracic echocardiographic studies performed during October 2010 at a tertiary care teaching hospital. Demographics, echocardiographic data, and clinical indications for each study were obtained from the echocardiographic reports. Demographic data recorded included age, gender, inpatient versus outpatient status, and specialty of referring provider. Echocardiographic information obtained included type of study (complete vs limited), use of contrast, presence and type of prosthetic valve, and presence of prior echocardiogram. If a prior study had been performed, any new findings were noted. Clinical indications and brief histories were obtained from the reports, and an electronic chart review was performed when this information was insufficient. This study was approved by the institutional review board.
Clinical Indications
The clinical indication for each echocardiographic study was classified by applying both the 2007 and the 2011 AUC. Each set of AUC was applied separately by two independent reviewers, and the classification by one set of AUC was not available to the reviewers when classifying by the other set of AUC. Each study was classified as appropriate, inappropriate, or uncertain if the indication for the study was classified as such in the AUC or unclassified if the indication for the study was not addressed by the AUC. In cases for which more than one indication was listed, the study was labeled appropriate if at least one appropriate indication was found. In cases in which discrepant classifications were made by the two reviewers, medical charts were reviewed and more information was obtained to further determine the most proper classification. A consensus was subsequently reached by the two reviewers to determine the final classification.
Statistical Analysis
Data are summarized using descriptive statistics. Continuous variables are expressed as mean ± SD and categorical variables as frequency (percentage). Univariate analyses were performed to compare characteristics of echocardiographic studies classified as appropriate, inappropriate, and unclassified. Chi-square or Fisher’s exact tests, as appropriate, were used to compare differences in categorical variables, and one-way analysis of variance was used for continuous variables. McNemar’s test was used to determine the significance of change in rates of appropriate, inappropriate, uncertain, and unclassified studies. SPSS version 17.0 (SPSS, Inc., Chicago, IL) was used for data analysis, and a two-tailed P value of ≤ .05 was regarded as statistically significant.
Results
Compared with the older 2007 AUC, applying the new 2011 AUC demonstrated a lower rate of unclassified studies (5.5% vs 12.5%, P < .001), higher rates of appropriate (92.2% vs 86.7%, P < .001) and inappropriate (1.8% vs 0.8%, P = .046) studies, and no significant change in the rate of uncertain studies (0.5% vs 0.0%, P = .157) ( Figure 1 ). Among the 384 transthoracic echocardiographic studies, 212 (55.2%) were performed in men, with a mean age of 64 years (range, 19–95 years), 261 (68.0%) were performed in inpatients, and 187 (48.7%) were ordered by cardiologists ( Table 1 , Figure 2 ). In comparison with appropriately indicated studies, inappropriate studies were more likely to be ordered in patients who had prior valve surgery or prior echocardiograms.
| Variable | Overall ( n = 384) | Appropriate ( n = 354) | Uncertain ( n = 2) | Inappropriate ( n = 7) | Unclassified ( n = 21) |
|---|---|---|---|---|---|
| Age (y) (mean ± SD) | 64 ± 16 | 65 ± 17 | 47 ± 31 | 64 ± 20 | 66 ± 10 |
| Male patients | 212 (55.2%) | 193 (54.5%) | 1 (50.0%) | 5 (71.4%) | 13 (61.9%) |
| Inpatients | 261 (68.0%) | 244 (68.9%) | 0 (0.0%) | 5 (71.4%) | 12 (57.1%) |
| Referring specialty † | |||||
| Cardiology | 187 (48.7%) | 175 (49.4%) | 2 (100.0%) | 3 (42.9%) | 7 (33.3%) |
| Cardiothoracic surgery | 9 (2.3%) | 3 (0.8%) | 0 (0.0%) | 2 (28.6%) | 4 (19.0%) |
| Noncardiac surgery | 16 (4.2%) | 14 (4.0%) | 0 (0.0%) | 1 (14.3%) | 1 (4.8%) |
| Hematology/oncology | 23 (6.0%) | 21 (5.9%) | 0 (0.0%) | 0 (0.0%) | 2 (9.5%) |
| Pulmonology | 13 (3.4%) | 13 (3.7%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Other medical specialty | 18 (4.7%) | 17 (4.8%) | 0 (0.0%) | 0 (0.0%) | 1 (4.8%) |
| General internist | 69 (18.0%) | 66 (18.6%) | 0 (0.0%) | 1 (14.3%) | 2 (9.5%) |
| Family medicine | 12 (3.1%) | 11 (3.1%) | 0 (0.0%) | 0 (0.0%) | 1 (4.8%) |
| Neurology | 11 (2.9%) | 10 (2.8%) | 0 (0.0%) | 0 (0.0%) | 1 (4.8%) |
| Emergency medicine | 12 (3.1%) | 11 (3.1%) | 0 (0.0%) | 0 (0.0%) | 1 (4.8%) |
| Obstetrics/gynecology | 6 (1.6%) | 5 (1.4%) | 0 (0.0%) | 0 (0.0%) | 1 (4.8%) |
| Other specialty | 8 (2.1%) | 8 (2.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Complete study | 341 (88.8%) | 315 (89.0%) | 1 (50.0%) | 7 (100.0%) | 18 (85.7%) |
| Definity ∗ contrast | 83 (21.7%) | 75 (21.2%) | 0 (0.0%) | 2 (28.6%) | 6 (28.6%) |
| Prior valve surgery † | 26 (6.8%) | 22 (6.2%) | 0 (0.0%) | 2 (28.6%) | 2 (9.5%) |
| Prior study ‡ | 120 (31.3%) | 106 (29.9%) | 1 (50.0%) | 5 (71.4%) | 8 (38.1%) |
| Change from prior study | 42 (34.7%) | 36 (34.0%) | 0 (0.0%) | 1 (20.0%) | 5 (62.5%) |
| Change in left ventricular ejection fraction | 22 (18.3%) | 17 (16.2%) | 0 (0.0%) | 1 (20.0%) | 4 (50.0%) |
| Change in valvular function | 15 (12.5%) | 15 (14.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
∗ Lantheus Medical Imaging (North Billerica, MA).
The most common indication classified as inappropriate per the 2011 AUC was routine surveillance of a prosthetic valve (<3 years after implantation) (28.6% of all inappropriate studies; Table 2 ). Other inappropriate indications were routine surveillance of significant valvular stenosis, suspected endocarditis in transiently febrile patients, routine perioperative evaluation in patients with no history of coronary artery disease (CAD), routine surveillance of ventricular function in patients with known CAD, or previously documented normal function in the absence of any clinical change. Of the 48 echocardiograms that could not be classified by the 2007 AUC, 27 (56.3%) were reclassified as appropriate, uncertain, or inappropriate by the 2011 AUC. Specifically, 21 (43.8%) were reclassified as appropriate, two (4.2%) as uncertain, and four (8.3%) as inappropriate ( Table 3 ). The most common indication that could not be classified by the 2007 AUC and is now considered appropriate by the 2011 AUC is the performance of TTE for assessment of patients in atrial fibrillation, which accounted for 15 studies (31% of previously unclassified studies). Other appropriate indications that were not classified by the original AUC include routine surveillance of a prosthetic valve (≥3 years after implantation), reevaluation of ascending aortic dilatation to assess expansion rates, reevaluation of known heart failure to guide therapy, optimization of left ventricular assist device settings, and reevaluation for signs or symptoms suggestive of left ventricular assist device–related complications. The two studies that were not classified before and were now reclassified as uncertain were performed for initial evaluation for cardiac resynchronization therapy device optimization after implantation and routine surveillance (≥2 years) of adult congenital heart disease after repair with no clinical change.
| Number of studies | AUC indication | Description of indication |
|---|---|---|
| Inappropriate | ||
| 2 (28.6%) | 48 | Routine surveillance of prosthetic valve (<3 y after implantation) with no suspected valve dysfunction |
| 1 (14.3%) | 40 | Routine surveillance (<1 y) of moderate or severe valvular stenosis without a clinical change |
| 1 (14.3%) | 53 | Suspected endocarditis in patient with transient fever without evidence of bacteremia or new murmur |
| 1 (14.3%) | 13 | Routine perioperative evaluation with no symptoms or signs of cardiovascular disease |
| 1 (14.3%) | 11 | Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam findings |
| 1 (14.3%) | 12 | Evaluation of LV function with prior ventricular function evaluation showing normal function and no change in clinical status or cardiac exam findings |
| Uncertain | ||
| 1 (4.3%) | 77 | Initial evaluation for CRT device optimization after implantation |
| 1 (4.3%) | 96 | Routine surveillance (>2 y) of adult congenital heart disease after complete repair with no clinical change |
| Unclassified | ||
| 15 (65.2%) | NA | Preoperative cardiac assessment in patients with histories of cardiovascular disease or at least one cardiovascular risk factor in the absence of clinical signs or symptoms |
| 2 (8.7%) | NA | Assessment of ventricular function after revascularization in the absence of a myocardial infarction |
| 2 (8.7%) | NA | Postoperative assessment of thoracic aortic surgery in the absence of clinical change |
| 1 (4.3%) | NA | Suspected endocarditis in patient with leukocytosis and recent dental procedure without evidence of fever, bacteremia, or new murmur |
| 1 (4.3%) | NA | Insufficient information to determine clinical indication |
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