Pediatric Appropriate Use Criteria for Outpatient Echocardiography: Practice Variations among Pediatric Cardiologists, Noncardiologist Subspecialists, and Primary Care Providers

Kourtidou, Soultana; Evers, Patrick D.; Jorgensen, Neal W.; Kronmal, Richard A.; Lewin, Mark B.; Schultz, Amy H.

doi:10.1016/j.echo.2017.08.014

Cited by 9 publications

(17 citation statements)

References 36 publications

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“…Other pediatric TTE AUC studies have observed diagnostic yield for “rarely appropriate” indications of 2%–9%. 10 , 11 In our study, “appropriate” studies had higher diagnostic yield than “rarely appropriate” studies (30% versus 15%, P < 0.01), however, the diagnostic yield of “may be appropriate” and “rarely appropriate” studies were not significantly different (18% versus 15%, P > 0.1). The latter finding is quite interesting and questions the AUC distinction between indications that are considered “rarely appropriate” and those that “may be appropriate.” All abnormal results discovered during “rarely appropriate” TTE were mild, but follow up was recommended in 89%.…”

Section: Discussioncontrasting

confidence: 61%

“…The percentage of “appropriate” rated studies is similar to previously published TTE AUC implementation studies (71%–77%). 10 – 12 Because this QI initiative was launched 1 year after the AUC publication, we cannot exclude whether the cohort’s exposure to the publication altered their ordering behavior before the baseline study. However, a recent study by Sachdeva et al 16 would argue against a significant impact of the AUC publication on ordering behavior.…”

Section: Discussionmentioning

confidence: 99%

“… 20 Additionally, prior studies have shown a discrepancy in TTE ordering appropriateness between primary care providers and cardiologists. 10 , 21 To what degree referring provider and parental/patient expectation of TTE does and should influence TTE ordering is an interesting question and deserving of future study, particularly in the setting of cost-conscious medicine and value-based reimbursement.…”

Section: Discussionmentioning

confidence: 99%

“…Several implementation studies have evaluated the use of AUC in the pediatric clinical setting. 10 – 13 …”

Section: Introductionmentioning

confidence: 99%

“…Our institution recently published an implementation study of AUC, wherein “rarely appropriate” indications comprised 14% of all TTE studies. 10 As a result of this finding, the project aim was to improve overall TTE ordering appropriateness (ie, mean AUC score) by 10% through AUC based educational interventions. We also sought to identify barriers to implementing AUC.…”

Section: Introductionmentioning

confidence: 99%

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A Quality Initiative to Improve Appropriate Use of Initial Outpatient Echocardiography Among Pediatric Cardiologists

Frandsen

Kourtidou

Tieder

et al. 2020

Pediatric Quality &Amp; Safety

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Introduction: Appropriate use criteria (AUC) guide initial transthoracic echocardiogram (TTE) use in outpatient pediatrics. We sought to improve pediatric cardiologist TTE ordering appropriateness (mean AUC score) with a quality improvement initiative. Methods: The outcome of interest was the prospective AUC score for all initial outpatient TTEs ordered between November 2016 and August 2017, categorized per the AUC: “appropriate” (score 7–9), “may be appropriate” (4–6), “rarely appropriate” (1–3). Interventions included a didactic review of 2014 AUC and participant documentation of AUC criteria for each TTE. Participants met quarterly to evaluate outcome, process, and balancing measures, intervention effectiveness, and to identify and mitigate barriers. Results: Twenty-two pediatric cardiologists participated. TTE appropriateness level before (n = 216) and after (n = 557) intervention was high. There was no significant difference in mean baseline and post-intervention AUC score (7.42 ± 1.87 versus 7.16 ± 2.87, P = 0.1), nor in TTE sensitivity (27% versus 25%, P > 0.1) as a balancing measure. Among baseline studies, 81% were “appropriate,” and 6% “rarely appropriate.” Among post-intervention studies, 76% were “appropriate,” and 11% “rarely appropriate.” Barriers identified to implementing AUC include TTE indications not specified by current AUC, expectations of referring provider or parent to perform TTE, consistent provider application of AUC, and ability of AUC to capture comprehensive clinical judgment. Conclusions: Although the mean AUC appropriateness level was high, we were able to identify significant barriers to the implementation of AUC. Future efforts should focus on the reduction of “rarely appropriate” TTE ordering.

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Section: Discussioncontrasting

confidence: 61%