Appropriate Use and Clinical Impact of Transthoracic Echocardiography

Abstract

IMPORTANCE Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. Appropriate use criteria (AUC) for echocardiography were developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate by AUC. However, the associations among TTE, AUC, and their clinical impact have not been well explored. OBJECTIVES To describe the proportion of TTEs that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by AUC. DESIGN AND SETTING Retrospective review of medical records from 535 consecutive TTEs at an academic medical center was performed. The TTEs were classified according to 2011 AUC by 2 cardiologists blinded to clinical impact and were assessed for clinical impact by 2 cardiologists blinded to AUC. Clinical impact was assigned to 1 of the following 3 categories: (1) active change in care, (2) continuation of current care, or (3) no change in care. PARTICIPANTS Five hundred thirty-five patients undergoing TTE. EXPOSURE Transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Prevalence of appropriate, inappropriate, and uncertain TTEs and prevalence of clinical impact subcategories. RESULTS Overall, 31.8% of TTEs resulted in an active change in care; 46.9%, continuation of current care; and 21.3%, no change in care. By 2011 AUC, 91.8% of TTEs were appropriate; 4.3%, inappropriate; and 3.9%, uncertain. We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%; P = .29). CONCLUSIONS AND RELEVANCE Although 9 in 10 TTEs were appropriate by 2011 AUC, fewer than 1 in 3 TTEs resulted in an active change in care, nearly half resulted in continuation of current care, and slightly more than 1 in 5 resulted in no change in care. The low rate of active change in care (31.8%) among TTEs mostly classified as appropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care.

Improving Appropriateness and Quality in Cardiovascular Imaging

“…23 Cardiac stress testing in patients with inappropriate indications is unlikely to identify prognostically significant ischemia. Cortigiani et al 10 showed that an SE performed for an inappropriate indication was associated with low likelihood of demonstrating ischemia and a good prognosis.…”

Impact of transthoracic echocardiography at district hospital level

“…This has been undervalued by previous studies. [12,15] Our study has shown that impact does not necessarily translate into a change in managementmany patients without a change in clinical status require followup, which is seen as a valid indication in itself in early and late stages of cardiac disease. [14] The major change in management proved to be rational prescription of medication.…”

“…[12,13] The diversity of patients' ages, comorbidities and sources of referral revealed the broad value of this investigative modality. The value of a prospective study is that single ECHO assessment in a nontertiary setting can immediately address a focused, clinical question or suspicion raised, and may have an immediate impact.…”

“…Our definition of impact is different from previous larger impact studies, undertaken either in tertiary settings or in community hospitals with specialised cardiology services. [12,13] A few older studies done at district hospitals either reviewed the impact more than 30 years ago, using only Mmode ECHO, or focused on intensive care units. [3,15,16] The lack of generalisability to current district hospital practice seems obvious, especially in resourceconstrained settings.…”

Vigilance in Mitral Regurgitation

“…For example, in a study examining consecutive all-comer echocardiographic studies at a tertiary care center, the investigators found that most studies were appropriate and that approximately a third resulted in change in care. 8 Notwithstanding the limitations, this study is an important step in understanding the practice patterns in surveillance of primary MR, a disease where timely surgical intervention is necessary to restore normal life expectancy. This work also represents the first step, that is, identifying the problem, in a quality assurance pathway, with data that can be used as a benchmark and metric in improving guideline adherence.…”