Assessment of inpatient multimodal cardiac imaging appropriateness at large academic medical centers

Abstract

BackgroundResponding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple imaging modalities in an inpatient environment.MethodsA retrospective study of the appropriateness of cardiac tests ordered by the inpatient General Internal Medicine (GIM) and Cardiology services at three Canadian academic hospitals was conducted over two one-month periods. Cardiac tests characterized were transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), single-photon emission tomography myocardial perfusion imaging (SPECT), and diagnostic cardiac catheterization.ResultsOverall, 553 tests were assessed, of which 99.8 % were classifiable by AUC. 91 % of all studies were categorized as appropriate, 4 % may be appropriate and 5 % were rarely appropriate. There were high rates of appropriate use of all modalities by GIM and Cardiology throughout. Significantly more appropriate diagnostic catheterizations were ordered by Cardiology than GIM (93 % vs. 82 %, p = <0.01). Cardiology ordered more appropriate studies overall (94 % vs. 88 %, p = 0.03) but there was no difference in the rate of rarely appropriate studies (3 % vs. 6 %, p = 0.23).ConclusionThe ACCF AUC captured the vast majority of clinical scenarios for multiple cardiac imaging modalities in this multi-centered study on Cardiology and GIM inpatients in the acute care setting. The rate of appropriate ordering was high across all imaging modalities. We recommend further work towards improving appropriate utilization of cardiac imaging resources focus on the out-patient setting.

Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings

“…Having said this, we were able to classify all patients in this study using this method. Others have also reported very high classification rates approaching 100% based on similar methods . Third, the retrospective nature of the study and the associated chart review to determine appropriateness precluded the ability for our data abstracters to abstract data in a blinded manner.…”

“…Bhatia and colleagues examined the appropriate use of inpatient cardiac noninvasive diagnostic testing, specifically transthoracic echocardiography (TTE), trans‐esophageal echocardiography (TEE), and single‐photon emission myocardial perfusion scanning (MPI) in a major university teaching center. They reported that, overall, 91% of tests were appropriate, 4% may be appropriate, and 5% were rarely appropriate . When broken down to constituent parts, 90% of TTEs were deemed to be appropriate, while 93% of single photon emission tomography (SPECT) were classified as appropriate as were 95% of TEEs.…”

Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare

“…There is a suggestion that clinical decision-making support tools can increase the relative proportion of several different imaging tests designated as appropriate, even within a year of implementation [20, 21]. This could also fulfill a role as an additional quality improvement measure, while helping to streamline utilization of noninvasive imaging techniques [22]. …”

Appropriate use criteria for transthoracic echocardiography: Are they relevant to European centers?

“…In the largest study to date, performed in 1812 patients from a single US academic center, 82% were appropriate, 12% were inappropriate, and 5% were uncertain. One in ten referrals at our center were considered inappropriate which is slightly higher than 2015 reports in the US (5%) and Canada (7%) but lower than those outside North America (15% to 20%) . In the US, compliance with the AUC is essential as requests for tests are only authorized if they comply with the radiology manager's precertification criteria which are in line with the AUC .…”

“…Prior revision of the 2007, AUC was prompted by several reports of unclassified studies which were clinically indicated and had an impact on patient management. However, data from centers outside the US suggest over 95% of TTEs can be classified by the 2011 AUC indicating these criteria could be applied overseas. Furthermore, a number of studies have found TTEs classified as appropriate have greater detection rates of new, unexpected, or treatable findings compared to inappropriate TTEs.…”