Revised Appropriate Use Criteria (AUC) for Echocardiography were published in 2011 and classify potential procedure indications as appropriate (score of 7 to 9), uncertain (score of 4 to 6), or inappropriate (score of 1 to 3). The appropriate utilization rate of transthoracic echocardiography in clinical practice using the revised AUC is unknown. The aim of the present study was to determine the appropriate utilization rate of echocardiography in a large number of consecutive studies in clinical practice and to determine the number of “unclassifiable” studies using the revised and expanded AUC. The clinical indication for transthoracic echocardiography (TTE) was determined on the basis of a detailed review of preprocedural clinical documentation. These clinical indications were further classified (when possible) into 1 of the 98 indications described in the 2011 AUC for echocardiography. From December 2010 to January 2011, 1,825 patients (mean age 63.2 years) underwent TTE for clinical reasons. Of the final study group of 1,820 patients, TTE was appropriate in 82%, inappropriate in 12.3%, and uncertain in 5.3%, and 0.4% studies were unclassifiable. The evaluation of symptoms potentially due to a cardiac etiology was the most common appropriate indication for TTE (27.5%). The most common inappropriate indication was routine surveillance (<1 year) of heart failure without a change in clinical status (2.5%). In conclusion, most TTE studies were appropriately ordered, and only a very small number of studies were unclassifiable.
Recent studies have demonstrated a temporal increase in cardiac imaging use without a commensurate increase in disease prevalence. To address this issue with respect to echocardiographic imaging, in 2007, the American College of Cardiology and the American Society of Echocardiography, in conjunction with other professional societies, published appropriate use criteria for echocardiography after conducting a review of common clinical scenarios where echocardiography is frequently considered. This publication classified 59 potential procedural indications as follows: appropriate (score of 7 to 9), uncertain (score of 4 to 6), and inappropriate (score 1 to 3). In 2011, an updated Appropriate Use Criteria (AUC) document for echocardiography was published. This document combines and updates the original combined transthoracic and transesophageal echocardiography AUC and the original stress echocardiography AUC published in 2008. We and others, have published single-center data regarding the appropriate use of transthoracic echocardiography (TTE) using the 2007 AUC document as a reference standard. To our knowledge, no previous reports have evaluated the appropriate utilization rates of TTE using the 2011 AUC update as a reference standard. The objective of the present study was to prospectively evaluate the appropriate utilization rates of TTE in a large consecutive number of patients and to determine whether the number of unclassifiable studies is now less using the revised, and purportedly more comprehensive, 2011 AUC document.
Methods
This was a prospective observational study. The Saint Luke’s Hospital institutional review board (Kansas City, Missouri) approved the study. The procedural indications for consecutive transthoracic echocardiographic studies ordered for clinically indicated reasons within Saint Luke’s Health System from December 1, 2010 to January 10, 2011 were reviewed. An indication for these procedures was determined by a detailed review of preprocedural clinical documentation using Saint Luke’s Health System medical records. These indications were then classified into 1 of the 98 indications as described in the 2011 AUC for TTE by 1 of 2 observers (H.R.P. or T.R.C.). The present study included all transthoracic echocardiographic studies performed for clinical indications on adults (aged ≥18 years), including inpatient and outpatient referrals. Transthoracic echocardiographic studies performed for research purposes or with insufficient preprocedural clinical data were excluded from the study. Consensus of the 2 observers was used when the indication was not obvious or when multiple indications were applicable. The frequencies of the AUC classifications were compared across inpatient and outpatient status using chi-square tests. Statistical significance was defined as p ≤0.05. All statistical analyses were performed by the Saint Luke’s Mid America Heart Institute Department of Biostatistics using SAS, version 9.2 (SAS Institute, Cary, North Carolina).
Results
A total of 1,825 transthoracic echocardiograms were performed during the study period. Of these 5 (0.3%) had insufficient clinical documentation and were excluded. The remaining 1,820 patients constituted the study group. The most common indications for TTE are listed in Table 1 , with indication descriptions from the 2011 AUC document. The studies were appropriately ordered for 1,493 patients (82%). The most common appropriate indication for outpatient and inpatient TTE (n = 500, 27.5%) was “symptoms potentially due to suspected cardiac etiology, including but not limited to dyspnea, shortness of breath, lightheadedness, syncope, transient ischemic attack, cerebrovascular events” (indication 1, appropriateness score 9). Evaluation of dyspnea was the most common appropriate indication for outpatient studies, and chest pain was the most common indication for inpatient studies. A total of 223 studies (12.3%) were inappropriately ordered. The most common inappropriate use in both outpatient and inpatient settings was “routine surveillance (<1 year) of heart failure (systolic or diastolic) with no change in clinical status or cardiac examination” (Indication 74, appropriateness score 2; n = 46, 2.5%). Ninety-six studies (5.3%) were classified as uncertain. The most common uncertain (3.1%) indication (outpatient and inpatient) was “routine surveillance (≥1 years) of heart failure (systolic or diastolic) when there is no change in clinical status or cardiac examination” (indication 75, appropriateness score 6). For an additional 8 transthoracic echocardiographic studies (0.4%), adequate clinical documentation was present; however, the studies were not classifiable using the appropriateness criteria. The indications for these 8 studies included patients with renal failure (n = 2), fatigue (n = 2), orthostatic hypotension (n = 2), and routine follow-up for adult congenital heart disease after 1 year (n = 2). A total of 970 studies (53.3%) were ordered as outpatient examinations and 850 (46.7%) as inpatient studies ( Table 2 ). Appropriate examinations were more likely to be ordered for hospitalized patients (88.7% inpatient appropriate vs 76.2% outpatient appropriate, p <0.0001). Inappropriate studies were more likely to be ordered in the outpatient setting (14.6% inappropriate outpatient vs 9.5% inappropriate inpatient, p = 0.0009). Uncertain studies were also more common in the outpatient setting (8.6% uncertain outpatient vs 1.5% uncertain inpatient, p <0.0001).
| Indication | Description ⁎ | Frequency | Cumulative Frequency | Appropriateness Score (1–9) |
|---|---|---|---|---|
| 1 | “Symptoms or conditions potentially related to suspected cardiac etiology, including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event” | 500 (27.5%) | 500 (27.5%) | Appropriate (9) |
| 5 | “Sustained or nonsustained atrial fibrillation, SVT, or VT’” | 139 (7.6%) | 639 (35.1%) | Appropriate (9) |
| 2 | “Prior testing that is concerning for heart disease or structural abnormality, including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers” | 114 (6.3%) | 753 (41.4%) | Appropriate (9) |
| 58 | “Suspected cardiovascular source of embolus” | 113 (6.25%) | 866 (47.65%) | Appropriate (9) |
| 9 | “Syncope when there are no other symptoms or signs of cardiovascular disease” | 81 (4.5%) | 947 (52.15%) | Appropriate (7) |
| 34 | “Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease” | 72 (4%) | 1,019 (56.15%) | Appropriate (9) |
| 73 | “Re-evaluation of known HF (systolic or diastolic) to guide therapy” | 68 (3.7%) | 1,087 (59.85%) | Appropriate (9) |
| 75 | “Routine surveillance (≥1 year) of HF (systolic or diastolic) when there is no change in clinical status or cardiac examination” | 57 (3.1%) | 1,144 (62.95%) | Uncertain (6) |
| 24 | “Initial evaluation of ventricular function following ACS” | 50 (2.7%) | 1,194 (66.65%) | Appropriate (9) |
| 74 | “Routine surveillance (<1 year) of HF (systolic or diastolic) when there is no change in clinical status or cardiac examination” | 46 (2.5%) | 1,240 (68.15%) | Inappropriate (2) |
| 91 | “Baseline and serial re-evaluations in a patient undergoing therapy with cardiotoxic agents” | 39 (2.1%) | 1,279 (70.25%) | Appropriate (9) |
| 11 | “Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac examination” | 35 (1.9%) | 1,314 (72.15%) | Inappropriate (3) |
| 84 | “Monitoring for rejection in a cardiac transplant recipient” | 29 (1.6%) | 1,343 (73.75%) | Appropriate (7) |
| 37 | “Re-evaluation of known valvular heart disease with a change in clinical status or cardiac examination or to guide therapy” | 27 (1.5%) | 1,370 (75.25%) | Appropriate (9) |
| 67 | “Initial evaluation of suspected hypertensive heart disease” | 24 (1.3%) | 1394 (%76.55) | Appropriate (8) |
| 41 | “Routine surveillance (≥1 year) of moderate or severe valvular stenosis without a change in clinical status or cardiac examination” | 22 (1.2%) | 1,416 (77.75%) | Appropriate (8) |
| 45 | “Routine surveillance (<1 year) of moderate or severe valvular regurgitation without a change in clinical status or cardiac examination” | 19 (1%) | 1,435 (78.75%) | Uncertain (6) |
| 46 | “Routine surveillance (≥1 year) of moderate or severe valvular regurgitation without change in clinical status or cardiac examination” | 18 (1%) | 1,453 (79.75%) | Appropriate (8) |
| 48 | “Routine surveillance (<3 years after valve implantation) of prosthetic valve if no known or suspected valve dysfunction” | 18 (1%) | 1,471 (80.75%) | Inappropriate (3) |
| 50 | “Evaluation of prosthetic valve with suspected dysfunction or a change in clinical status or cardiac examination” | 18 (1%) | 1,489 (81.75%) | Appropriate (9) |
| 15 | “Evaluation of suspected pulmonary hypertension, including evaluation of right ventricular function and estimated pulmonary artery pressure” | 17 (0.9%) | 1,506 (82.65%) | Appropriate (9) |
| 22 | “Evaluation of a patient without chest pain but with other features of an ischemic equivalent or laboratory markers indicative of ongoing MI” | 17 (0.9%) | 1,523 (83.55%) | Appropriate (8) |
| 66 | “Routine re-evaluation for surveillance of known ascending aortic dilation or history of aortic dissection without a change in clinical status or cardiac examination when findings would not change management or therapy” | 15 (0.8%) | 1,538 (84.35%) | Inappropriate (3) |
| 18 | “Re-evaluation of known pulmonary hypertension if change in clinical status or cardiac examination or to guide therapy” | 13 (0.7%) | 1,551 (85.1%) | Appropriate (9) |
| 52 | “Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur” | 13 (0.7%) | 1,564 (85.8%) | Appropriate (9) |
| 68 | “Routine evaluation of systemic hypertension without symptoms or signs of hypertensive heart disease” | 12 (0.65%) | 1,576 (87.1%) | Inappropriate (3) |
| 76 | “Initial evaluation or re-evaluation after revascularization and/or optimal medical therapy to determine candidacy for device therapy and/or to determine optimal choice of device” | 12 (0.65%) | 1,588 (87.75%) | Appropriate (9) |
| 6 | “Asymptomatic isolated sinus bradycardia” | 10 (0.5%) | 1,598 (88.25%) | Inappropriate (2) |
| 10 | “Initial evaluation of ventricular function (e.g., screening) with no symptoms or signs of cardiovascular disease” | 10 (0.5%) | 1,608 (88.75%) | Inappropriate (2) |
| 14 | “Routine perioperative evaluation of cardiac structure and function before noncardiac solid organ transplantation” | 10 (0.5%) | 1,618 (89.3%) | Uncertain (6) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
