Ritu Sachdeva, MD, FASE, FACC, FAAP, Children’s Healthcare of Atlanta, Atlanta, GA

In collaboration with the ASE’s Council on Pediatric and Congenital Heart Disease and other pediatric and cardiology organizations and societies, the American College of Cardiology (ACC) recently released the first document on pediatric appropriate use criteria (AUC), addressing the appropriateness of transthoracic echocardiograms during the initial outpatient pediatric cardiology evaluation. It was purposefully restricted to the initial outpatient evaluation given its high utilization in this setting.

Appropriate use criteria have been used in adult cardiology for almost a decade now. Because of the disproportionate growth in cardiac imaging in adult patients and the wide variability in physician ordering patterns unexplained by patient demographics and risk factors, payers started looking into ways to limit testing by using approaches such as preauthorization. However, these controls potentially limited patient access to appropriate imaging procedures, thereby delaying diagnosis, incurring higher costs with layered diagnostic testing, and encouraged use of proprietary algorithms inconsistent with the published literature. In response, the ACC Foundation created an AUC Task Force to formulate the AUC for various imaging modalities and procedures in order to guide physicians regarding the utility of the procedure in the context of the current scientific evidence, healthcare resources, and physician judgment. The primary intent of the AUC was to evaluate patterns of care by physicians and serve as a framework for appropriateness of care.

The task force has established a rigorous and well-defined methodology to develop AUC, a process that has been refined over the years. The first pediatric initiative took advantage of the vast experience in adult cardiology. Consisting of nominated participants from the ASE and other societies, the writing group developed a document identifying the indications, formulating definitions, and highlighting the assumptions associated with the development of the AUC. An expert panel consisting of 30 representatives from various pediatric cardiology subspecialties, general pediatrics, and quality/outcomes disciplines reviewed the document, which was then revised based on the feedback. The appropriateness of each indication was quantified by an independent 15 member rating panel using a scoring scale of 1 to 9. The median scores from this rating panel were used to rate each indication as Appropriate (median score 7 to 9), May Be Appropriate (median score 4 to 6), or Rarely Appropriate (median score 1 to 3).

One hundred thirteen indications were identified, each describing various clinical scenarios for which an echocardiogram could be ordered in an outpatient setting. The indications were divided into 9 categories, some representing the most common presenting symptoms such as chest pain, murmur, syncope, and palpitations, whereas other more rare indications were intentionally kept broad. The document provides flow diagrams (decision trees) to help determine the AUC rating for a specific indication as well as relevant guidelines and references for each indication category. In addition, important assumptions and definitions relevant to the AUC are included in the document to help with application of the AUC in clinical practice.

Similar to adult cardiology, AUC are expected to have an important impact on clinical practice in pediatrics and pediatric cardiology. It is important to remember that the AUC provide guidance as to when it is reasonable to do a test. An “Appropriate” rating does not imply that the test must always be performed, and a “Rarely Appropriate” rating does not imply that the test should never be performed. Individual patient circumstances and sound clinical judgment can supersede the AUC rating. Categorizing an indication as “May be Appropriate” or “Rarely Appropriate” should not be used to deny reimbursement, as there may be individual clinical scenarios dictating the need for testing that have not been included in the document. Rather than focusing on each individual case, the AUC should be used to evaluate patterns of appropriate care by various providers. The AUC have served as an important quality improvement tool in adult cardiology. Recent studies using educational interventions amongst providers have shown a significant reduction in the rate of echocardiograms ordered for “Rarely Appropriate” indications. Healthcare facilities and accreditation bodies have also used AUC in adults as part of quality improvement, accreditation, and resource utilization activities. Implementation studies helped in identifying gaps in the AUC, thereby leading to the development of the revised document. Similar activities related to education and quality improvement are anticipated with regard to the pediatric AUC document.

The first pediatric AUC document has been designed to support decision-making in clinical practice and will hopefully help improve patient care and outcomes in a cost-effective manner. This initial effort has laid the foundation for development of other AUC in pediatric echo as well as other quality improvement projects. The AUC may require revisions based on the gaps identified through implementation studies, changing scientific evidence, and available healthcare resources.