Hostname: page-component-586b7cd67f-rcrh6 Total loading time: 0 Render date: 2024-11-26T09:27:31.107Z Has data issue: false hasContentIssue false
  • English
  • Français

Appropriate Use Criteria for paediatric echocardiography in an outpatient practice: a validation study

Published online by Cambridge University Press:  25 April 2018

Mark J. Cartoski ,
Meghan Kiley  and
Philip J. Spevak
Mark J. Cartoski*
Affiliation:
Department of Paediatrics, Johns Hopkins University, Baltimore, MD, USA Division of Paediatric Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
Meghan Kiley
Affiliation:
Department of Paediatrics, Johns Hopkins University, Baltimore, MD, USA
Philip J. Spevak
Affiliation:
Department of Paediatrics, Johns Hopkins University, Baltimore, MD, USA Division of Paediatric Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
*
Author for correspondence: M. J. Cartoski, Division of Paediatric Cardiology, Bloomberg Children’s Center, 1800 Orleans Street, Baltimore, MD 21287, USA. Tel: 410 955 5517; Fax: 410 955 0897; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Although transthoracic echocardiography is the dominant imaging modality in CHD, optimal utilisation is unclear. We assessed whether adherence to the paediatric Appropriate Use Criteria for outpatient transthoracic echocardiography could reduce inappropriate use without missing significant cardiac disease.

Methods

Using the Appropriate Use Criteria, we determined the indication and appropriateness rating for each initial echocardiogram performed at our institution during calendar year 2014 (N=1383). Chart review documented ordering provider training, patient demographics, and study result, classified as normal, abnormal, or abnormal motivating treatment within a 2-year follow-up period. We tested whether provider training level or patient age correlated with echocardiographic findings or appropriateness rating.

Results

We found that 83.9% of echocardiograms were normal and that 66.7% had an appropriate indication. Nearly all abnormal results and all results motivating treatment were in appropriate studies, giving an odds ratio of 2.73 for an abnormal result if an appropriate indication was present (95% confidence interval 1.92–3.89, p<0.001). None of the remaining initial abnormal results with less than appropriate indications became significant, resulting in treatment over 2 years. Results suggest a potential reduction in imaging volume of as much as 33% with application of the criteria. Cardiologists ordered nearly all studies resulting in treatment but also more echocardiograms with less appropriate indications. Most examinations were in older patients; however, most abnormal results were in patients younger than 1 year.

Conclusions

The Appropriate Use Criteria can be used to safely reduce echocardiography volume while still detecting significant heart disease.

Keywords

Echocardiographypaediatricappropriate usequality improvement
Type
Original Articles
Information
Cardiology in the Young , Volume 28 , Issue 6 , June 2018 , pp. 862 - 867
Check for updates
Copyright
© Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Srivastava, S, Allada, V, Younoszai, A, et al. Determinants of pediatric echocardiography laboratory productivity: analysis from the second survey of the American Society of Echocardiography Committee on Echocardiography Laboratory Productivity. J Am Soc Echocardiogr 2016; 29: 1009–1015.CrossRefGoogle ScholarPubMed
2. Lopez, L, Colan, SD, Frommelt, PC, et al. Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010; 23: 1413–1430.CrossRefGoogle ScholarPubMed
3. Matulevicius, SA, Rohatgi, A, Das, SR, Price, AL, DeLuna, A, Reimold, SC. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med 2013; 173: 1600–1607.CrossRefGoogle ScholarPubMed
4. Sachdeva, R, Allen, J, Benavidez, OJ, et al. Pediatric appropriate use criteria implementation project: a multicenter outpatient echocardiography quality initiative. J Am Coll Cardiol 2015; 66: 1132–1140.CrossRefGoogle Scholar
5. Campbell, RM, Douglas, PS, Eidem, BW, et al. ACC/AAP/AHA/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology appropriate use criteria task force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol 2014; 64: 2039–2060.Google Scholar
6. Douglas, PS, Garcia, MJ, Haines, DE, et al. ACSF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011; 57: 1126–1166.CrossRefGoogle Scholar
7. Patil, HR, Coggins, TR, Kusnetzky, LL, Main, ML. Evaluation of appropriate use of transthoracic echocardiography in 1,820 consecutive patients using the 2011 revised appropriate use criteria for echocardiography. Am J Cardiol 2012; 109: 1814–1817.CrossRefGoogle Scholar
8. Puri, P, Carroll, J, Parson, B. Cost savings associated with implementation of peer-reviewed appropriate use criteria for percutaneous coronary interventions. Am J Cardiol 2016; 117: 1289–1293.CrossRefGoogle ScholarPubMed
9. Boggan, JC, Schulteis, RD, Donahue, M, Simel, DL. Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency. BMJ Qual Saf 2016; 25: 57–62.CrossRefGoogle Scholar
10. Safa, R, Aggarwal, S, Misra, A, Kobayashi, D. Application of appropriate use criteria for initial transthoracic echocardiography in an academic outpatient pediatric cardiology program. Pediatr Cardiol 2017; 38: 1282–1287.CrossRefGoogle Scholar
11. Chamberlain, RC, Pelletier, JH, Blanchard, S, et al. Evaluating appropriate use of pediatric echocardiograms for chest pain in outpatient clinics. J Am Soc Echocardiogr 2017; 30: 708–713.CrossRefGoogle ScholarPubMed
12. Rose-Felker, K, Kelleman, MS, Campbell, RM, Oster, ME, Sachdeva, R. Appropriate use and clinical impact of echocardiographic “evaluation of murmur” in pediatric patients. Congenit Heart Dis 2016; 11: 721–726.CrossRefGoogle ScholarPubMed
13. Phelps, HM, Kelleman, MS, McCracken, CE, et al. Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope. Echocardiography. 2017; 34: 441–445.CrossRefGoogle ScholarPubMed
14. Lang, SM, Bolin, E, Hardy, S, Tang, X, Collins, RT 2nd. Diagnostic yield of outpatient pediatric echocardiograms: impact of indications and specialty. Pediatr Cardiol 2017; 38: 162–169.CrossRefGoogle ScholarPubMed
15. Lang, SM, Bolin, E, Daily, JA, Tang, X, Thomas Collins, R 2nd. Appropriateness and diagnostic yield of inpatient pediatric echocardiograms. Congenit Heart Dis 2017; 12: 210–217.CrossRefGoogle ScholarPubMed
16. Johnson, ER, Etheridge, SP, Minich, LL, Bardsley, T, Heywood, M, Menon, SC. Practice variation and resource use in the evaluation of pediatric vasovagal syncope: are pediatric cardiologists over-testing? Pediatr Cardiol 2014; 35: 735–738.CrossRefGoogle ScholarPubMed
17. Nguyen, T, Fundora, MP, Welch, E, et al. Application of the pediatric appropriate use criteria for chest pain. J Pediatr. 2017; 185: 124–128.CrossRefGoogle Scholar
18. Angoff, GH, Kane, DA, Giddins, N, et al. Regional implementation of a pediatric cardiology chest pain guideline using SCAMPs methodology. Pediatrics. 2013; 132: e1010–e1017.CrossRefGoogle ScholarPubMed
19. Rosenbloom, J. American Society of Echocardiography 2014 coding and reimbursement newsletter. 2014. Retrieved June 10, 2017, from http://asecho.org/wordpress/wp-content/uploads/2014/06/2014-reimbursement-newsletter-.pdf.Google Scholar
20. Yi, MS, Kimball, TR, Tsevat, J, Mrus, JM, Kotagal, UR. Evaluation of heart murmurs in children: cost-effectiveness and practical implications. J Pediatr 2002; 141: 504–511.CrossRefGoogle ScholarPubMed
21. McCrindle, BW, Shaffer, KM, Kan, JS, et al. Cardinal clinical signs in the differentiation of heart murmurs in children. Arch Pediatr Adolesc Med 1996; 150: 169–174.CrossRefGoogle ScholarPubMed
22. Friedman, KG, Kane, DA, Rathod, RH, et al. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011; 128: 239–245.CrossRefGoogle ScholarPubMed
23. Khairandish, Z, Jamali, L, Haghbin, S. Role of anxiety and depression in adolescents with chest pain referred to a cardiology clinic. Cardiol Young 2017; 27: 125–130.CrossRefGoogle ScholarPubMed
24. Rose-Felker, K, Kelleman, MS, Campbell, RM, Sachdeva, R. Appropriateness of outpatient echocardiograms ordered by pediatric cardiologists or other clinicians. J Pediatr. 2017; 184: 137–142.CrossRefGoogle ScholarPubMed
25. Dudzinkski, DM, Bhatia, RS, My, M, Isselbacher, EM, Picard, MH, Weiner, RB. Effect of educational intervention on the rate of rarely appropriate outpatient echocardiograms ordered by academic cardiologists: a randomized clinical trial. JAMA Cardiol 2016; 1: 805–812.CrossRefGoogle Scholar
26. Sachdeva, R, Douglas, PS, Kelleman, MS, et al. Educational intervention for improving the appropriateness of transthoracic echocardiograms ordered by pediatric cardiologists. Congenit Heart Dis 2017; 12: 373–381.CrossRefGoogle ScholarPubMed
27. Sachdeva, R, Douglas, PS, Kelleman, MS, McCracken, CE, et al. Effect of release of the first pediatric appropriate use criteria on transthoracic echocardiogram ordering practice. Am J Cardiol 2016; 118: 1545–1551.CrossRefGoogle ScholarPubMed
28. Sachdeva, R, Kelleman, KS, McCracken, CE, et al. Physician attitudes toward the first pediatric appropriate use criteria and engagement with educational intervention to improve the appropriateness of outpatient echocardiography. J Am Soc Echocardiogr 2017; 30: 926–931.CrossRefGoogle ScholarPubMed