TY - JOUR
T1 - Pediatric Appropriate Use Criteria Implementation Project
T2 - A Multicenter Outpatient Echocardiography Quality Initiative
AU - Sachdeva, Ritu
AU - Allen, Joseph
AU - Benavidez, Oscar J.
AU - Campbell, Robert M.
AU - Douglas, Pamela S.
AU - Eidem, Benjamin W.
AU - Gold, Lara
AU - Kelleman, Michael S.
AU - Lopez, Leo
AU - McCracken, Courtney E.
AU - Stern, Kenan W.D.
AU - Weiner, Rory B.
AU - Welch, Elizabeth
AU - Lai, Wyman W.
N1 - Funding Information:
Determination of indication for TTE may not have been uniform among centers. In addition, there may be an element of bias, because site investigators were not blinded to the results of TTE, even though the results of TTE were reviewed after assigning the AUC indication. Also, the clinicians were made aware of data collection for the study, and this could have influenced their decision to order TTEs. Although the AUC document applies to a TTE ordered by any provider, our study included only patients that were evaluated by a pediatric cardiologist because the orders received for TTEs by other providers lacked details that were needed to assign an AUC indication. Even though the bulk of outpatient TTE's in the real world are ordered by pediatric cardiologists, the findings of this study may not be generalizable as the distribution of appropriateness rating may vary when the TTE is ordered by primary care providers versus a specialist. We would also like to acknowledge that this investigation was not performed by an independent team as some of the authors on this study were involved with the development of the AUC document. In addition, this study was supported by the American College of Cardiology Appropriate Use Criteria Task Force.
Publisher Copyright:
© 2015 American College of Cardiology Foundation.
PY - 2015/9/8
Y1 - 2015/9/8
N2 - Background Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability. Objectives This study sought to determine the appropriateness of TTE as currently performed in pediatric cardiology clinics, diagnostic yield of TTE for various AUC indications, and any gaps in the AUC document. Methods Data were prospectively collected from patients undergoing initial outpatient TTE in 6 centers. TTE indications (appropriate [A], may be appropriate [M], or rarely appropriate [R]) and findings (normal, incidental, or abnormal) were recorded. Results Of the 2,655 studies ordered by 102 physicians, indications rated A, M, and R were found in 1,876 (71%), 316 (12%), and 319 studies (12%), respectively, and 144 studies (5%) were unclassifiable. Twenty-four of 113 indications (21%) were not used. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for 75% of indications rated R. Pathologic murmur had the highest yield of abnormal findings (40%). Odds of an abnormal finding in an A or M TTE were 6 times that of R (95% confidence interval [CI]: [2.8 to 12.8]). Abnormal findings were more common in patients <1 year of age than in those >10 years of age (odds ratio: 6.4; 95% CI: 4.7 to 8.7). Age was a significant predictor of an abnormal finding after adjusting for indication and site (p < 0.001). Conclusions Most TTEs ordered in pediatric cardiology clinics were for indications rated A. AUC ratings successfully stratified indications based on the yield of abnormal findings. This study identified differences in the yield of TTE based on patient age and most common indications rated R. These findings should inform quality improvement efforts and future revisions of the AUC document.
AB - Background Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability. Objectives This study sought to determine the appropriateness of TTE as currently performed in pediatric cardiology clinics, diagnostic yield of TTE for various AUC indications, and any gaps in the AUC document. Methods Data were prospectively collected from patients undergoing initial outpatient TTE in 6 centers. TTE indications (appropriate [A], may be appropriate [M], or rarely appropriate [R]) and findings (normal, incidental, or abnormal) were recorded. Results Of the 2,655 studies ordered by 102 physicians, indications rated A, M, and R were found in 1,876 (71%), 316 (12%), and 319 studies (12%), respectively, and 144 studies (5%) were unclassifiable. Twenty-four of 113 indications (21%) were not used. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for 75% of indications rated R. Pathologic murmur had the highest yield of abnormal findings (40%). Odds of an abnormal finding in an A or M TTE were 6 times that of R (95% confidence interval [CI]: [2.8 to 12.8]). Abnormal findings were more common in patients <1 year of age than in those >10 years of age (odds ratio: 6.4; 95% CI: 4.7 to 8.7). Age was a significant predictor of an abnormal finding after adjusting for indication and site (p < 0.001). Conclusions Most TTEs ordered in pediatric cardiology clinics were for indications rated A. AUC ratings successfully stratified indications based on the yield of abnormal findings. This study identified differences in the yield of TTE based on patient age and most common indications rated R. These findings should inform quality improvement efforts and future revisions of the AUC document.
KW - echocardiography
KW - outpatient
KW - pediatric cardiology
UR - http://www.scopus.com/inward/record.url?scp=84940495066&partnerID=8YFLogxK
U2 - 10.1016/j.jacc.2015.06.1327
DO - 10.1016/j.jacc.2015.06.1327
M3 - Article
C2 - 26337992
AN - SCOPUS:84940495066
SN - 0735-1097
VL - 66
SP - 1132
EP - 1140
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 10
ER -