Leo Lopez, MD, FACC, FAAP, FASE, Council Vice Chair

Echocardiography is the primary diagnostic modality for patients with pediatric and congenital heart disease (CHD). As this patient population grows, the need for echocardiograms has increased significantly, and quality improvement (QI) efforts in pediatric and congenital echocardiography have become crucial components in the delivery of health care to these patients. This report will review some of the past and current QI initiatives.

Since its creation in 1996, the Intersocietal Accreditation Commission (IAC) has developed and established minimum standards in terms of facility, equipment, and staffing for accreditation of pediatric echocardiography laboratories. In addition, members of the ASE Pediatric and CHD Council have recently surveyed North American pediatric echocardiography laboratories and are currently analyzing data to establish productivity standards for centers caring for children with acquired and CHDs. These standards will include daily and annual data on sonographer and attending physician productivity as well as equipment and technological needs based on the total number of studies done at each site per year.

Patient selection is an important component of QI initiatives. A recent joint publication by the ASE and other organizations outlines appropriate use criteria (AUC) for adult echocardiography, providing over 20 categories and almost a hundred criteria for transthoracic echocardiography alone. A similar document does not exist for pediatric echocardiography, partly because of the potential for an impossibly extensive list if criteria are developed for each cardiac malformation and its variants before and after intervention. However, a task force involving the American College of Cardiology (ACC), ASE, and the Society of Pediatric Echocardiography (SOPE) is currently developing AUC for pediatric echocardiography in the outpatient setting.

Study performance is dependent on standardized protocols, and the ASE Pediatric and CHD Council has published guidelines documents over the last 8 years on several topics: the performance of pediatric transthoracic echocardiograms, pediatric transesophageal echocardiograms, and fetal echocardiograms; quantification methods during a pediatric echocardiogram; and targeted echocardiograms in the Neonatal Intensive Care Unit. In addition, it is currently developing several publications on the role of multimodality imaging for specific CHD such as tetralogy of Fallot, transposition of the great arteries, and congenital coronary anomalies, thereby establishing standard protocols for the evaluation of these lesions.

A major challenge to study interpretation has been the inconsistent nomenclature and widely varied coding systems for CHDs. Controversies in nomenclature originate partly from the different approaches used to describe the morphology of cardiac malformations and their variants, such as seen with heterotaxy syndrome. The varied and somewhat heterogeneous coding systems that are currently in use include multiple American and European codes created by either pediatric cardiology or cardiac surgical organizations, codes from the 9 ^th , 10 ^th , or 11 ^th revision of the International Classification of Diseases (ICD-9, ICD-10, or ICD-11) developed by the World Health Organization, and the Current Procedural Terminology (CPT) codes established by the American Medical Association. Efforts by the International Society for the Nomenclature of Paediatric and CHDs to cross-match these codes have resulted in the International Pediatric and Congenital Cardiac Code, which now provides a framework in which to establish a common diagnostic and procedural coding system.

Study interpretation also involves the ability to distinguish normal measurements from abnormal ones, especially since many disease states can have significant effect on the sizes of cardiovascular structures. However, the sizes of cardiovascular structures in children are affected by body size. Currently available reference values have been established at single centers and are limited by relatively small sample sizes and a paucity of neonatal data, and most databases do not account for the effects of sex and race. More recently, the Pediatric Heart Network, a multicenter program funded by the National Institute of Health, has utilized the quantification guidelines in order to develop a large multicenter database of measurements from normal children. This initiative will then establish universally available normal reference values adjusted for the effects of body size, age, gender, and race.

Finally, the ACC has recently established a task force to measure QI in all aspects of pediatric cardiology, including a subgroup to identify and define quality metrics in noninvasive imaging. One example involves comprehensive quantification of diagnostic errors in echocardiography within an institution using a recently published taxonomy system to categorize errors in pediatric echocardiography based on type, severity, preventability, and cause. Most centers establish periodic QI meetings to discuss errors identified ad hoc during a specified period of time without a standard approach, and this quality metric should help centers organize the data. Other quality metrics currently being developed include the assessment of study and report completeness, variability in measurements and grading of valvar regurgitation severity, timing to report critical findings, and image quality.