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King SJ, Williamson C, Weickert TP, Miller PF, Hinderliter AL, Stouffer GA. Applicability of Appropriate Use Criteria for Echocardiography in an Underserved Population. J Am Soc Echocardiogr 2024:S0894-7317(24)00351-1. [PMID: 38986917 DOI: 10.1016/j.echo.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Sara J King
- Department of Medicine, Stanford University, Palo Alto, California
| | - Clark Williamson
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Thelsa P Weickert
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - Paula F Miller
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - Alan L Hinderliter
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
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2
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Leuchter RK, Gulhar R, Maynick JD, Dardick LD, Vorobiof G, Tabibiazar R, Yang RM, Sarkisian CA, Woo HE. Evaluation of an Electronic Health Record Tool to Identify Echocardiograms That Do Not Change Clinical Care. J Am Soc Echocardiogr 2023; 36:1329-1332. [PMID: 37640087 PMCID: PMC11162694 DOI: 10.1016/j.echo.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Richard K Leuchter
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Radhika Gulhar
- Olive-View UCLA, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Lawrence D Dardick
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gabriel Vorobiof
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ramin Tabibiazar
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Robert M Yang
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Catherine A Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; Greater Los Angeles VA Healthcare System Geriatrics Research Education and Clinical Center (GRECC), Los Angeles, California
| | - Hawkin E Woo
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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3
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Nolan M, Stanton T. Natriuretic Peptides and Echocardiography: When We Use Tests to Guide Testing. Heart Lung Circ 2023; 32:1271-1273. [PMID: 38052501 DOI: 10.1016/j.hlc.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Mark Nolan
- Department of Medicine, Peter MacCallum (Peter Mac) Cancer Centre, Melbourne, Vic, Australia; Cardiovascular Imaging, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia.
| | - Tony Stanton
- Department of Cardiology, Sunshine Coast University Hospital, Sunshine Coast, Qld, Australia
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4
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Harrison D, Misra A, Pahwa A, Muradali K, Sherman S. Things We Do for No Reason™: Routinely obtaining repeat transthoracic echocardiography for acute decompensation of known chronic heart failure. J Hosp Med 2023; 18:934-937. [PMID: 36739110 DOI: 10.1002/jhm.13053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/19/2022] [Accepted: 01/10/2023] [Indexed: 02/06/2023]
Affiliation(s)
- Darren Harrison
- Section of Cardiology, Department of Medicine, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Arunima Misra
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Amit Pahwa
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Komal Muradali
- Department of Medicine, Division of Hospital Medicine, University of Texas Southwestern, Houston, Texas, USA
| | - Stephanie Sherman
- Section of General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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5
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Kadado AJ, Pervaiz A, Gobeil K, Shikari S, Elder P, Battisha A, Walia R, Hiser W, Lagu T, Pack QR. Electrocardiogram changes as predictors for new imaging findings in repeat transthoracic echocardiography. Future Cardiol 2023; 19:487-495. [PMID: 37721317 PMCID: PMC10599417 DOI: 10.2217/fca-2023-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
Aim: To determine if electrocardiogram (EKG) findings may be a useful tool to predict changes in repeat transthoracic echocardiogram (TTE). Methods: We evaluated patients who underwent TTE during hospitalization and their EKGs, and whether findings differed between studies. Results: Of 229 hospitalized patients who underwent repeat TTE, 183 (80%) were abnormal. Each minor and major EKG abnormality resulted in a 1.8 (1.2 to 2.6; p = 0.002) and 2.1 (1.3 to 3.3; p < 0.001) increased odds of abnormal imaging on TTE, respectively. The negative likelihood ratio for an unchanged EKG to predict an unchanged TTE was 0.68 (95% CI = 0.62 to 0.73). Conclusion: Among hospitalized patients with prior imaging results, an unchanged EKG predicts an unchanged TTE.
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Affiliation(s)
- Anis John Kadado
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - Abdullah Pervaiz
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - Kyle Gobeil
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Saima Shikari
- Division of Cardiovascular Medicine, University of Kentucky Medical Center, Lexington, KY 40536, USA
| | - Petal Elder
- Department of Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - Ayman Battisha
- Department of Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - Ritika Walia
- Department of Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - William Hiser
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
| | - Tara Lagu
- Division of Hospital Medicine, Northwestern Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Quinn R Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01199, USA
- Institute for Healthcare Delivery & Population Science at University of Massachusetts Medical School – Baystate, Springfield, MA 01199, USA
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6
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Canning C, Guo J, Narang A, Thomas JD, Ahmad FS. The Emerging Role of Artificial Intelligence in Valvular Heart Disease. Heart Fail Clin 2023; 19:391-405. [PMID: 37230652 PMCID: PMC11267973 DOI: 10.1016/j.hfc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Valvular heart disease (VHD) is a morbid condition in which timely identification and evidence-based treatments can lead to improved outcomes. Artificial intelligence broadly refers to the ability for computers to perform tasks and problem solve like the human mind. Studies applying AI to VHD have used a variety of structured (eg, sociodemographic, clinical) and unstructured (eg, electrocardiogram, phonocardiogram, and echocardiograms) and machine learning modeling approaches. Additional researches in diverse populations, including prospective clinical trials, are needed to evaluate the effectiveness and value of AI-enabled medical technologies in clinical care for patients with VHD.
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Affiliation(s)
- Caroline Canning
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA. https://twitter.com/carolinecanning
| | - James Guo
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
| | - Akhil Narang
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA. https://twitter.com/AkhilNarangMD
| | - James D Thomas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA. https://twitter.com/jamesdthomasMD1
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA; Division of Health and Biomedical informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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7
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Gallaher J, Stone L, Marquart G, Freeman C, Zonies D. Reply to Letter to the Editor. Injury 2022; 53:2900. [PMID: 35672194 DOI: 10.1016/j.injury.2022.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Lucas Stone
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Grant Marquart
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Christopher Freeman
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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8
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Association between Wait Time for Transthoracic Echocardiography and 28-Day Mortality in Patients with Septic Shock: A Cohort Study. J Clin Med 2022; 11:jcm11144131. [PMID: 35887895 PMCID: PMC9321017 DOI: 10.3390/jcm11144131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023] Open
Abstract
Background: the optimal timing of Transthoracic echocardiography (TTE) performance for patients with septic shock remains unexplored. Methods: a retrospective cohort study included patients with septic shock in the MIMIC-Ⅲ database. Risk-adjusted restricted cubic splines modeled the 28-day mortality according to time elapsed from ICU admission to receive TTE. The cut point when a smooth curve inflected was selected to define early and delayed group. We applied propensity score matching (PSM) to ensure our findings were reliable. Causal mediation analysis was used to assess the intermediate effect of fluid balance within 72 h after ICU admission. Results: 3264 participants were enrolled and the risk of 28-day mortality increased until the wait time was around 10 h (Early group) and then was relatively flat afterwards (Delayed group). A beneficial effect of early TTE in terms of the 28-day mortality was observed (HRs 0.73−0.78, all p < 0.05) in the PSM. The indirect effect brought by the fluid balance on day 2 and 3 was significant (both p = 0.006). Conclusion: early TTE performance might be associated with lower risk-adjusted 28-day mortality in patients with septic shock. Better fluid balance may have mediated this effect. A wait time within 10 h after ICU may represent a threshold defining progressively increasing risk.
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9
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Dong D, Wang Y, Wang C, Zong Y. Effects of transthoracic echocardiography on the prognosis of patients with acute respiratory distress syndrome: a propensity score matched analysis of the MIMIC-III database. BMC Pulm Med 2022; 22:247. [PMID: 35752780 PMCID: PMC9233371 DOI: 10.1186/s12890-022-02028-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) has high mortality and is mainly related to the circulatory failure.Therefore, real-time monitoring of cardiac function and structural changes has important clinical significance.Transthoracic echocardiography (TTE) is a simple and noninvasive real-time cardiac examination which is widely used in intensive care unit (ICU) patients.The purpose of this study was to analyze the effect of TTE on the prognosis of ICU patients with ARDS.
Methods The data of ARDS patients were retrieved from the MIMIC-III v1.4 database and patients were divided into the TTE group and non-TTE group. The baseline data were compared between the two groups. The effect of TTE on the prognosis of ARDS patients was analyzed through multivariate logistic analysis and the propensity score (PS). The primary outcome was the 28-d mortality rate. The secondary outcomes included pulmonary artery catheter (PAC) and Pulse index continuous cardiac output (PiCCO) administration, the ventilator-free and vasopressor-free days and total intravenous infusion volume on days 1, 2 and 3 of the mechanical ventilation. To illuminate the effect of echocardiography on the outcomes of ARDS patients,a sensitivity analysis was conducted by excluding those patients receiving either PiCCO or PAC. We also performed a subgroup analysis to assess the impact of TTE timing on the prognosis of patients with ARDS.
Results A total of 1,346 ARDS patients were enrolled, including 519 (38.6%) cases in the TTE group and 827 (61.4%) cases in the non-TTE group. In the multivariate logistic regression, the 28-day mortality of patients in the TTE group was greatly improved (OR 0.71, 95%CI 0.55–0.92, P = 0.008). More patients in the TTE group received PAC (2% vs. 10%, P < 0.001) and the length of ICU stay in the TTE group was significantly shorter than that in the non-TTE group (17d vs.14d, P = 0.0001). The infusion volume in the TTE group was significantly less than that of the non-TTE group (6.2L vs.5.5L on day 1, P = 0.0012). Importantly, the patients in the TTE group were weaned ventilators earlier than those in the non-TTE group (ventilator-free days within 28 d: 21 d vs. 19.8 d, respectively, P = 0.071). The Kaplan–Meier survival curves showed that TTE patients had significant lower 28-day mortality than non-TTE patients (log-rank = 0.004). Subgroup analysis showed that TTE after hemodynamic disorders can not improve prognosis (OR 1.02, 95%CI 0.79–1.34, P = 0.844).
Conclusion TTE was associated with improved 28-day outcomes in patients with ARDS.
Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02028-5.
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Affiliation(s)
- Daoran Dong
- Department of ICU, Shaanxi Provincial People's Hospital, No. 256, Youyi West Road, Beilin District, Xi'an, Shaanxi, China
| | - Yan Wang
- Department of ICU, Shaanxi Provincial People's Hospital, No. 256, Youyi West Road, Beilin District, Xi'an, Shaanxi, China
| | - Chan Wang
- Department of ICU, Shaanxi Provincial People's Hospital, No. 256, Youyi West Road, Beilin District, Xi'an, Shaanxi, China
| | - Yuan Zong
- Department of ICU, Shaanxi Provincial People's Hospital, No. 256, Youyi West Road, Beilin District, Xi'an, Shaanxi, China.
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10
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Gallaher J, Stone L, Marquart G, Freeman C, Zonies D. Do I really need this transthoracic ECHO? An over-utilized test in trauma and surgical intensive care units. Injury 2022; 53:1631-1636. [PMID: 34996627 DOI: 10.1016/j.injury.2021.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/03/2021] [Accepted: 12/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Clinical use of transthoracic echocardiogram (TTE) in intensive care units (ICU) has dramatically increased without clear guidance on validated assessment indications, appropriateness, and patient value. METHODS A retrospective analysis of consecutive TTEs performed among patients admitted to a tertiary trauma/surgical ICU over 2.5 years was performed. A bivariate analysis and Poisson regression was used to compare patients who received a TTE. Sensitivity analysis was performed to assess patient factors that predict change in management based on TTE. An abnormal exam was defined as having at least one of the following: ejection fraction < 55%, wall motion, pericardial effusion, pericardial effusion, or other significant abnormality including filling defect. The effect on management was derived from clinical course. We hypothesize that these studies are usually normal and rarely lead to changes in clinical management. RESULTS 912 TTEs were performed in 806 patients. The median age was 68 years (IQR 57, 77) and 63.5% were male. Syncope (21.7%) or hypotension/hypovolemia (20.5%) were the most common indications for a TTE. In total, 39.4% TTEs were abnormal and only 7.6% resulted in a change in management. Predictive factors associated with an abnormal exam included: age >50, serum troponin ≥0.1 ng/ml, abnormal ECG, and clinical suspicion of heart failure or acute myocardial infarction. A troponin cutoff level <0.25 ng/mL was the most reliable factor to predict no change in management after TTE with a negative predictive value of 94.3% (95% CI 93.1, 95.3). CONCLUSION TTE is commonly used for patient assessment in critically ill surgical patients but the majority of exams are normal without change in clinical management. Certain patient factors, such as troponin level, may help distinguish which patients would benefit from this diagnostic test. Given the considerable cost associated with TTE and the minimal effect on management, guidelines on appropriate use would provide improved patient value.
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Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Lucas Stone
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Grant Marquart
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Christopher Freeman
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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Khan SI, Qaisar SM, Pachori RB. Automated classification of valvular heart diseases using FBSE-EWT and PSR based geometrical features. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103445] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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12
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Kini V, Breathett K, Groeneveld PW, Ho PM, Nallamothu BK, Peterson PN, Rush P, Wang TY, Zeitler EP, Borden WB. Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000105. [PMID: 35189687 PMCID: PMC9909614 DOI: 10.1161/hcq.0000000000000105] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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13
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Danyluk A, Winchester D. Appropriateness and subsequent management of inpatient echocardiograms: An evaluation of low value care. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 12:100070. [PMID: 38559600 PMCID: PMC10978172 DOI: 10.1016/j.ahjo.2021.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 04/04/2024]
Abstract
Study objective Transthoracic echocardiograms (TTE) are perceived to be overused and multiple TTEs are often ordered within one inpatient visit with unclear utility. This study identified inpatients who received multiple TTEs to determine the appropriateness, results, and subsequent management of repeat TTEs. Design Retrospective Cohort Study. Setting Single academic medical center. Participants Subjects over age 18 who underwent >1 TTE during hospitalization in 2020. Interventions N/A. Main outcome measures Appropriateness of TTE, TTE results, subsequent changes in management. Results Of the 875 subjects, the average age was 60 years old with a male predominance (57.8%). In comparing the first and second TTE results, the frequency of new abnormal findings decreased significantly from 44.7% to 15.1% (p < .0001). Changes in clinical management in relation to the TTEs decreased from 47.1% to 32.5% (p < .0001), of which medication changes were most common. The majority of tests were appropriate, with a slight increase of inappropriate TTEs from 0.6% to 1.8% (p < .0001) between first and second TTEs. Conclusions While the rate of inappropriate TTE use increased after the initial TTE, the overall rate of inappropriate use was very small indicating that stricter adherence to AUC would not appreciably reduce duplication of inpatient TTEs. The non-negligible frequency of new abnormal findings for the repeat TTEs at 15% cannot be ignored. Our data suggests that the assumption that repeat TTEs are in large part unnecessary is more complicated than originally thought.
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Affiliation(s)
- A.B. Danyluk
- University of Florida College of Medicine, United States of America
| | - D.E. Winchester
- University of Florida College of Medicine, United States of America
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
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Kusunose K, Okushi Y, Okayama Y, Zheng R, Nakai M, Sumita Y, Ise T, Yamaguchi K, Yagi S, Fukuda D, Yamada H, Soeki T, Wakatsuki T, Sata M. Use of Echocardiography and Heart Failure In-Hospital Mortality from Registry Data in Japan. J Cardiovasc Dev Dis 2021; 8:jcdd8100124. [PMID: 34677193 PMCID: PMC8536984 DOI: 10.3390/jcdd8100124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/16/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Echocardiography requires a high degree of skill on the part of the examiner, and the skill may be more improved in larger volume centers. This study investigated trends and outcomes associated with the use and volume of echocardiographic exams from a real-world registry database of heart failure (HF) hospitalizations. Methods: This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). A first analysis was performed to assess the trend of echocardiographic examinations between 2012 and 2016. A secondary analysis was performed to assess whether echocardiographic use was associated with in-hospital mortality in 2015. Results: During this period, the use of echocardiography grew at an average annual rate of 6%. Patients with echocardiography had declining rates of hospital mortality, and these trends were associated with high hospitalization costs. In the 2015 sample, a total of 52,832 echocardiograms were examined, corresponding to 65.6% of all HF hospital admissions for that year. We found that the use and volume of echocardiography exams were associated with significantly lower odds of all-cause hospital mortality in heart failure (adjusted odds ratio (OR): 0.48 for use of echocardiography and 0.78 for the third tertile; both p < 0.001). Conclusions: The use of echocardiography was associated with decreased odds of hospital mortality in HF. The volumes of echocardiographic examinations were also associated with hospital mortality.
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Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
- Correspondence: ; Tel.: +81-88-633-7851; Fax: +81-88-633-7894
| | - Yuichiro Okushi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Yoshihiro Okayama
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima 770-8503, Japan;
| | - Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Michikazu Nakai
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.N.); (Y.S.)
| | - Yoko Sumita
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.N.); (Y.S.)
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima 770-8503, Japan;
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima 770-8503, Japan; (Y.O.); (R.Z.); (T.I.); (K.Y.); (S.Y.); (D.F.); (T.S.); (T.W.); (M.S.)
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15
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Alotaibi AA, Zahrani M, Baflah A, Alkhattabi A, Algaydi A, Alsulami F, Tayyeb SZ. The Rate of Appropriate Adult Transthoracic Echocardiogram at King Abdulaziz University Hospital Based on Appropriate Use Criteria of 2011, 2017, and 2019. Cureus 2021; 13:e16262. [PMID: 34377602 PMCID: PMC8349210 DOI: 10.7759/cureus.16262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/07/2022] Open
Abstract
Background: Transthoracic echocardiography (TTE) is a basic method for cardiovascular disease diagnosis and treatment. Studies done to assess the appropriate use of TTE in the Kingdom of Saudi Arabia (KSA) are scarce. Objectives: To assess the pattern of ordering TTE in King Abdulaziz University Hospital (KAUH) and the appropriateness of its ordering. Methods: A retrospective study was done from October to November 2018 at KAUH, Echo lab, Jeddah City, KSA. Patients, more than 18 years who had TTE at KAUH were included. Results: The criteria used were the 2019 criteria for most patients and the orders were appropriate for 77.9% of the 954 patients. Orders were significantly inappropriate for patients who had older age, and the number of indications were significantly higher for those whose orders were - "maybe appropriate" (M). The anesthesia department for outpatients and the surgical department for inpatients ordered a significantly high number of inappropriate requests. Inpatients had a significantly higher percentage of "appropriate" (A) orders, and a significant positive correlation was present between patients’ age and number of indications. Conclusion: There is a need to maximize compliance with AUCs and its effect on clinical results should be evaluated.
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Affiliation(s)
| | | | - Aseel Baflah
- Cardiology, King Abdulaziz University Hospital, Jeddah, SAU
| | | | - Amaal Algaydi
- Cardiology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Farah Alsulami
- Cardiology, King Abdulaziz University Hospital, Jeddah, SAU
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16
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Liu B, Cai LD, Wang Y. Association between delayed transthoracic echocardiography and in-hospital mortality in type A acute aortic dissection-associated ST-segment elevated myocardial infarction. J Thorac Dis 2021; 13:2923-2932. [PMID: 34164183 PMCID: PMC8182513 DOI: 10.21037/jtd-20-3470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study evaluates the association between transthoracic echocardiography (TTE) timing and in-hospital mortality among individuals presenting with ST-segment elevated myocardial infarction (STEMI) complicating type A acute aortic dissection (TAAAD). Methods This cohort study obtained the data of previously published case reports from searches of PubMed (1990–2020), and adults with STEMI secondary to TAAAD were finally included. Delayed TTE (dTTE) exposure was defined as when the TTE test was made available after antithrombotic management for STEMI due to an initially missed diagnosis of TAAAD. The primary outcome of interest was in-hospital mortality, comparing individuals with dTTE and those with emergency TTE (eTTE). The odds ratio (OR) with 95% confidence interval (CI) were calculated to provide an estimate of association. Results A total of 109 individuals with a mean age of 56.7 [standard deviation (SD) 12.9] years, and of whom 75 were men (68.8%) presenting with STEMI complicating TAAAD were included. Of all patients, 68 (62.4%) had a dTTE test, which tended to be associated with increased in-hospital mortality after adjustment (OR, 2.320; 95% CI, 0.743–7.248). The association between dTTE and in-hospital death was significant only among patients presenting with a high-risk examination (HRE) (OR, 11.196; 95% CI, 1.322–94.803) and with surgical therapy (OR, 5.375; 95% CI, 1.080–26.700), and not among those presenting with negative HRE (OR, 0.150; 95% CI, 0.016–1.397) and no surgical therapy (OR, 0.177; 95% CI, 0.008–4.018). Conclusions This study found an association between dTTE and increased in-hospital mortality in TAAAD-associated STEMI patients with surgical management. This association warrants further investigation.
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Affiliation(s)
- Bei Liu
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li-Dong Cai
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Wang
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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17
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Kossaify A. Quality Assurance and Improvement Project in Echocardiography Laboratory: The Pivotal Importance of Organizational and Managerial Processes. Heart Views 2021; 22:35-44. [PMID: 34276887 PMCID: PMC8254161 DOI: 10.4103/heartviews.heartviews_112_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/04/2021] [Indexed: 11/04/2022] Open
Abstract
Echocardiography plays a vital role in the diagnosis and management of cardiovascular conditions. Echocardiography use is progressively increasing nowadays, and this is correlated to the evolving echo indications, to the relatively new available echocardiography modes (tissue Doppler imaging, speckle tracking imaging, three-dimensional mode, etc.) and modalities (transthoracic, transesophageal, and intracardiac) along with the various available clinical approaches (point of care echo, portable echo, etc.). Quality assurance in echocardiography is correlated to appropriate use criteria, adequate equipment, standardization of performance and reporting, along with timely storage and archiving. Quality improvement plan must target strategic planning, with metrics and timeline for assessment and re-assessment of results. Improvement project aims to ensure and enhance conformity with appropriate use criteria and standardization, timely completion of exams and reports, detection of discrepancies, and continuous improvement of knowledge and skills. Strategic planning is essential in this context in order to develop organizational and managerial processes, with regular auditing for a highly professional and advanced level of echocardiography, while ensuring teamwork and standards of ethical values.
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Affiliation(s)
- Antoine Kossaify
- Division of Cardiology, University Hospital Notre Dame Des Secours, Byblos, Lebanon.,School of Medicine and Medical Sciences (SMMS), USEK University, Kaslik, Lebanon
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18
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Echocardiogram Utilization Patterns and Association With Mortality Following Severe Traumatic Brain Injury. Anesth Analg 2021; 132:1060-1066. [PMID: 32815871 DOI: 10.1213/ane.0000000000005110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) can result in left ventricular dysfunction, which can lead to hypotension and secondary brain injuries. Although echocardiography is often used to examine cardiovascular function in multiple clinical settings, its use and association with outcomes following severe TBI are not known. To address this gap, we used the National Trauma Data Bank (NTDB) to describe utilization patterns of echocardiography and examine its association with mortality following severe TBI. METHODS A retrospective cohort study was conducted using a large administrative trauma registry maintained by the NTDB from 2007 to 2014. Patients >18 years with isolated severe TBI, and without concurrent severe polytrauma, were included in the study. We examined echocardiogram utilization patterns (including overall utilization, factors associated with utilization, and variation in utilization) and the association of echocardiography utilization with hospital mortality, using multivariable logistic regression models. RESULTS Among 47,808 patients, echocardiogram was utilized as part of clinical care in 2548 patients (5.3%). Clinical factors including vascular comorbidities and hemodynamic instability were associated with increased use of echocardiograms. Nearly half (46.0%, 95% confidence interval [CI], 40.3%-51.7%) of the variation in echocardiogram utilization was explained at the individual hospital level, above and beyond patient and injury factors. Exposure to an echocardiogram was associated with decreased odds of in-hospital mortality following severe TBI (adjusted odds ratio [OR] = 0.77; 95% CI, 0.69-0.87; P < .001). CONCLUSIONS Echocardiogram utilization following severe TBI is relatively low, with wide variation in use at the hospital level. The association with decreased in-hospital mortality suggests that the information derived from echocardiography may be relevant to improving patient outcomes but will require confirmation in further prospective studies.
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19
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Shah S, Gupta T, White CJ, Jain S, Ramee E, Qamruddin S, Kemmerly SA. Optimizing cardiovascular imaging in Staphylococcus aureus endocarditis. Echocardiography 2021; 38:574-581. [PMID: 33704836 DOI: 10.1111/echo.15022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The shift toward value-based health care drives physicians to examine opportunities to optimize use of healthcare resources. There is discordance between providers' use of cardiovascular imaging (CVI) in assessing patients for infective endocarditis (IE) with Staphylococcus aureus bacteremia (SAB). An evidence-based algorithm was created to minimize variation of CVI use. The primary objective was to ensure sensitivity of the algorithm to recommend CVI in patients suspected of IE. METHODS A retrospective review evaluated patients at Ochsner Medical Center who developed SAB between 1/1/13 and 12/31/14. Predefined patient demographics, use of CVI, outcomes, and 12-week follow-up for readmission after first positive blood culture were collected from chart review. The created algorithm was applied retrospectively to determine its sensitivity and specificity in recommending the right CVI test. RESULTS 181 patients admitted were admitted with SAB, of which 114 (63%) were male. There were 115 TTEs and 55 TEEs performed. Out of 15 patients diagnosed with IE, 3 were found on TTE and 12 were found on TEE. The algorithm would have recommended a TEE in all 15 patients who had high-risk features for IE and a true diagnosis of IE, suggesting a sensitivity of 100% and specificity of 74.7% for the algorithm to have recommended a highly sensitive CVI modality. CONCLUSION This algorithm optimizes CVI for diagnosing IE in patients with SAB. As healthcare adapts to a value-based system, use of best-practice algorithms will promote consistency in practice among providers and help optimize patient outcomes and use of resources.
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Affiliation(s)
- Sangeeta Shah
- Department of Cardiology, Pauley Heart Center, Virginia Commonwealth University Health Sciences, Richmond, VA, USA
| | - Tripti Gupta
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Christopher J White
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Surma Jain
- University of Queensland Ochsner School of Medicine, Brisbane, Australia.,Department of Pulmonary and Critical Care, Ochsner Clinical Foundation, New Orleans, LA, USA
| | - Emily Ramee
- University of Queensland Ochsner School of Medicine, Brisbane, Australia.,Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Salima Qamruddin
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Sandra A Kemmerly
- Department of Infectious Disease, Ochsner Clinic Foundation, New Orleans, LA, USA
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20
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Leis B, Bare I, Marshall K, Buschau E, Penner L, Keith C, De Villiers JS, Orvold J. Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol. CJC Open 2020; 3:516-523. [PMID: 34027356 PMCID: PMC8129432 DOI: 10.1016/j.cjco.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022] Open
Abstract
Background Routine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing). Methods We developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG. Results Among 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008). Conclusion We achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology.
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Affiliation(s)
- Benjamin Leis
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Idris Bare
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kirsten Marshall
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Elise Buschau
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Penner
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Cassandra Keith
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - J S De Villiers
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Jason Orvold
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
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21
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Amadio JM, Bouck Z, Sivaswamy A, Chu C, Austin PC, Dudzinski D, Nesbitt GC, Edwards J, Yared K, Wong B, Hansen M, Weinerman A, Thavendiranathan P, Johri AM, Rakowski H, Picard MH, Weiner RB, Bhatia RS. Impact of Appropriate Use Criteria for Transthoracic Echocardiography in Valvular Heart Disease on Clinical Outcomes. J Am Soc Echocardiogr 2020; 33:1481-1489. [PMID: 32893052 DOI: 10.1016/j.echo.2020.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The association between appropriate use criteria for transthoracic echocardiography (TTE) and clinical outcomes is unknown for patients with valvular heart disease (VHD). The aim of this study was to identify the association of TTE appropriateness with downstream cardiac tests and clinical outcomes in patients with VHD over 365 days. METHODS A subset of 2,297 patients with VHD across six Ontario academic hospitals was selected from the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial and linked to administrative databases. Each patient's index TTE was classified as "rarely appropriate" (rA) versus "appropriate" (comprising "appropriate" and "may be appropriate" TTE according to the 2011 appropriate use criteria). Overall, 431 of 452 patients with rA TTE were matched 1:1 with patients with appropriate TTE using propensity scores to account for measured confounding. RESULTS Matched patients with rA TTE were less likely to undergo repeat TTE (relative risk, 0.46; 95% CI, 0.33-0.66) or cardiac catheterization (relative risk, 0.27; 95% CI, 0.16-0.47) at 90 days compared with patients with appropriate TTE. rA TTE was significantly associated with a decreased hazard of aortic valve intervention (hazard ratio, 0.40; 95% CI, 0.14-0.42), all-cause hospitalization (hazard ratio, 0.44; 95% CI, 0.34-0.57), and death (hazard ratio, 0.31; 95% CI, 0.15-0.66) over 365 days of follow-up. CONCLUSIONS Patients with appropriate TTE for VHD were more likely to undergo subsequent cardiac testing within 90 days and valve intervention within 1 year than those with a rA TTE. The 2011 appropriate use criteria for TTE have important clinical implications for outcomes in patient with VHD.
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Affiliation(s)
- Jennifer M Amadio
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Zachary Bouck
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Cherry Chu
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | | | - David Dudzinski
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Jeremy Edwards
- Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kibar Yared
- The Scarborough Hospital, Toronto, Ontario, Canada
| | - Brian Wong
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Hansen
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Amer M Johri
- Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Harry Rakowski
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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22
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Vignon P. Critical care echocardiography: diagnostic or prognostic? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:909. [PMID: 32953709 PMCID: PMC7475398 DOI: 10.21037/atm-20-3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Philippe Vignon
- Medical-surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.,Inserm CIC 1435, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
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23
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Nagre AS. Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Ann Card Anaesth 2020; 22:302-308. [PMID: 31274494 PMCID: PMC6639886 DOI: 10.4103/aca.aca_88_18] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transthoracic echocardiography is a potent and appealing diagnostic tool by virtue of rapidity, noninvasiveness, and repeatability. Focus-assessed transthoracic echocardiography (FATE) forms quick guidance to interpret the echocardiographic information and relates it to the clinical context. It can be applied in the perioperative period, intensive care units (ICUs), and emergency situations, in trauma and as resuscitation aids. FATE intents to assess cardiac function including contractility, chamber size and hypertrophy, valvular dysfunction, cardiac tamponade, and pericardial and pleural effusions. Thence, FATE has become a quintessential scanning tool perioperatively and in ICUs.
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Affiliation(s)
- Amarja Sachin Nagre
- Department of Anaesthesia, Kamalnayan Bajaj Hospital, Aurangabad,Maharashtra, India
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24
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Khalili A, Drummond J, Ramjattan N, Zeltser R, Makaryus AN. Diagnostic and treatment utility of echocardiography in the management of the cardiac patient. World J Cardiol 2020; 12:262-268. [PMID: 32774778 PMCID: PMC7383355 DOI: 10.4330/wjc.v12.i6.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Echocardiograms are an incredibly useful diagnostic tool due to their lack of harmful radiation, the relative ease and speed with which they can be performed, and their almost ubiquitous availability. Unfortunately, the advantages that support the use of echocardiography can also lead to the overuse of this technology. We sought to evaluate the physician perceived impact echocardiography has on patient management.
AIM To evaluate the physician perceived impact echocardiography has on patient management.
METHODS Surveys were distributed to the ordering physician for echocardiograms performed at our institution over a 10-wk period. Only transthoracic echocardiograms performed on the inpatient service were included. Surveys were distributed to either the attending physician or the resident physician listed on the echocardiogram order. The information requested in the survey focused on the indication for the study and the perceived importance and effect of the study. Observational statistical analysis was performed on all of the answers from the collected surveys.
RESULTS A total of 103 surveys were obtained and analyzed. The internal medicine (57%) and cardiology (37%) specialties ordered the most echocardiograms. The most common reason for ordering an echocardiogram was to rule out a diagnosis (38.2%). Only 27.5% of physicians reported that the echocardiogram significantly affected patient care, with 18.6% reporting a moderate effect, and 30.4% reporting a mild effect. A total of 19.6% of physicians stated that there was no effect on patient management. Additionally, 43.1% of physicians reported that they made changes in patient management due to no change having occurred in the disease, 11.8% reported that changes in management were based on the recommendation of a specialist, and only 9.8% reported that further imaging was ordered due to the results of the echocardiogram. The majority of physicians (67.6%) considered an echocardiogram to be “somewhat essential” in the management of adult inpatients, with only 15.7% considering it “essential”.
CONCLUSION The majority of physicians surveyed report the echocardiogram had only a mild effect on management with only 27.5% reporting a significant effect. However, the majority of physicians (83.3%) perceived an echocardiogram to be somewhat or entirely essential for management. Only 9.8% reported the echo led to further imaging. These insights into ordering physician reasoning should help guide better definition of the optimal and ideal use of echocardiography.
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Affiliation(s)
- Ariella Khalili
- North Shore Hebrew Academy, Great Neck, NY 11020, United States
| | - Jennifer Drummond
- Department of Internal Medicine, Tufts Medical Center, Boston, MA 10211, United States
| | - Neiman Ramjattan
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY 11554, United States
| | - Roman Zeltser
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY 11554, United States
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, United States
| | - Amgad N Makaryus
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY 11554, United States
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, United States
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25
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Salik JR, Sen S, Picard MH, Weiner RB, Dudzinski DM. The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit. Echocardiography 2019; 36:631-638. [PMID: 30969477 DOI: 10.1111/echo.14314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/27/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU. METHODS Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator. RESULTS Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101). CONCLUSION Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.
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Affiliation(s)
- Jonathan R Salik
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Sounok Sen
- Cardiology Division, Duke University, Durham, North Carolina
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - David M Dudzinski
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Intensive Care Unit, Massachusetts General Hospital, Boston, Massachusetts
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26
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Pack QR, Priya A, Lagu T, Pekow PS, Schilling JP, Hiser WL, Lindenauer PK. Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction. JAMA Intern Med 2019; 179:1176-1185. [PMID: 31206134 PMCID: PMC6580445 DOI: 10.1001/jamainternmed.2019.1051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes. OBJECTIVE To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019. EXPOSURES Rates of transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate. RESULTS Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results. CONCLUSIONS AND RELEVANCE In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.
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Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Joshua P Schilling
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - William L Hiser
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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Urja P, Walters RW, Vivekanandan R, Kumar M, Abdulghani S, Hari Belbase R, Zook N, Mahesh Alla V. Trends in the use of echocardiography in patients with Staphylococcus aureus bacteremia: an analysis using the Nationwide Inpatient Sample data. Echocardiography 2019; 36:1625-1632. [PMID: 31471983 DOI: 10.1111/echo.14473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/29/2019] [Accepted: 08/15/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Infective endocarditis occurs in approximately 10%-30% of patients with Staphylococcus aureus bacteremia (SaB). Guidelines recommend echocardiography in patients with SaB and risk factors for infective endocarditis in the absence of any obvious source of infection. Herein, we explored the trends in the use of echocardiography in patients with SaB and its relationship to outcomes using a large national database. METHOD All patients with a principal discharge diagnosis of SaB were identified using the National Inpatient Sample database from 2001 to 2014. Procedure code 88.72 was used to identify echocardiography. Logistic regression models were estimated to identify the year-over-year trends in echocardiogram, predictors of use, and association with mortality. RESULTS From 2001 to 2014, there were 668 423 hospitalizations with SaB diagnosis and 86 387 (12.9%) had echocardiogram. The rate of echocardiography increased from 10.7% in 2001 to 15.2% in 2014 (ptrend < 0.001). Major predictors of echocardiogram usage were younger age, male gender, presence of sepsis, valvular or congenital heart disease, prosthetic heart valve (PHV), cardiac implantable electronic device (CIED), hemodialysis, and drug abuse. The adjusted rates of echocardiography increased from approximately 10% to 15% in hospitalizations without risk factors for IE while for high-risk groups like PHV and CIED it remained constant at 30% and 19%, respectively. Echocardiography was associated with 31% lower odds of in-hospital mortality. CONCLUSION The increase in echocardiography rate was largely attributable to increased use in those without risk factors while usage in those with PHV and CIED remained much lower than expected. Echocardiography use was associated with lower risk-adjusted mortality. These findings require further study and confirmation.
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Affiliation(s)
- Prakrity Urja
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska
| | - Renuga Vivekanandan
- Department of Infectious Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Mukund Kumar
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Saadi Abdulghani
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Ram Hari Belbase
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Nina Zook
- School of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Venkata Mahesh Alla
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
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28
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Haji K, Wong C, Neil C, Cox N, Mulligan A, Wright L, Vogrin S, Marwick TH. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract 2019; 6:91-96. [PMID: 31516721 PMCID: PMC6733360 DOI: 10.1530/erp-19-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/07/2019] [Indexed: 11/08/2022] Open
Abstract
Background Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying 'rarely appropriate' echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography. Method A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018. Results Groups undergoing Handheld ultrasound (n = 76, 58 (46.5-72.5) years, 53 males, 78% outpatients) and standard echocardiography (n = 72, 61 (49.0-71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group (P < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound, P = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group, P < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients. Conclusion Handheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.
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Affiliation(s)
- Kawa Haji
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Chiew Wong
- Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher Neil
- Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Nicholas Cox
- Cardiology Department, Western Health, Melbourne, Australia
| | | | - Leah Wright
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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29
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Patel KP, Saleem M, Forte MJ, Mills JD, Alqahtani F, Desai A, Manivannan S. System-Based Intervention Using Electronic Medical Records and Its Potential to Decrease the Overuse of Transthoracic Echocardiography. J Am Soc Echocardiogr 2019; 32:1253-1255. [PMID: 31279620 DOI: 10.1016/j.echo.2019.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/14/2019] [Accepted: 05/19/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Kinjan P Patel
- Heart and Vascular Institute of West Virginia University Hospital, Morgantown, West Virginia
| | - Maryam Saleem
- Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Michael J Forte
- Pulmonary and Critical Care Medicine, West Virginia University, Morgantown, West Virginia
| | - James D Mills
- Heart and Vascular Institute of West Virginia University Hospital, Morgantown, West Virginia
| | - Fahad Alqahtani
- Heart and Vascular Institute of West Virginia University Hospital, Morgantown, West Virginia
| | - Aanad Desai
- Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Shanthi Manivannan
- Department of Medicine, West Virginia University, Morgantown, West Virginia
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30
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Obeng-Okyere P, Norbu T, Hahn H. Point of Care Use of an Appropriate Use Criteria Smartphone App for Echocardiography. J Am Soc Echocardiogr 2019; 32:1048-1049. [PMID: 31204080 DOI: 10.1016/j.echo.2019.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/01/2019] [Accepted: 05/05/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Paul Obeng-Okyere
- Department of Internal Medicine, Kettering Medical Center, Kettering, Ohio
| | - Tsering Norbu
- Department of Internal Medicine, Kettering Medical Center, Kettering, Ohio
| | - Harvey Hahn
- Department of Cardiovascular Medicine, Kettering Medical Center, Kettering, Ohio
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31
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Camerini F, Fabris E, Sinagra G. Appropriateness, inappropriateness and waste of resources: Unfulfilled expectations? Eur J Intern Med 2019; 63:15-18. [PMID: 31006508 DOI: 10.1016/j.ejim.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Fulvio Camerini
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
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32
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Kozak PM, Trumbo SP, Christensen BW, Leverenz DL, Shotwell MS, Kingeter AJ. Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians. Int J Cardiovasc Imaging 2019; 35:1259-1263. [DOI: 10.1007/s10554-019-01572-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
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33
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Law TK, Bouck Z, Yin XC, Dudzinski D, Myers D, Nesbitt GC, Edwards J, Yared K, Wong B, Hansen M, Weinerman A, Shadowitz S, Farkouh M, Thavendiranathan P, Udell J, Johri A, Chow CM, Rakowski H, Picard MH, Weiner RB, Bhatia RS. Association Between Transthoracic Echocardiography Appropriateness and Echocardiographic Findings. J Am Soc Echocardiogr 2019; 32:667-673.e4. [PMID: 30846322 DOI: 10.1016/j.echo.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown. METHODS As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease. RESULTS There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60). CONCLUSIONS Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications.
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Affiliation(s)
- Tamryn K Law
- Women's College Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | | | - X Cindy Yin
- Women's College Hospital, Toronto, Ontario, Canada
| | - David Dudzinski
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Dorothy Myers
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Jeremy Edwards
- Echocardiogram and Vascular Lab, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kibar Yared
- The Scarborough Hospital, Scarborough, Ontario, Canada
| | - Brian Wong
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Hansen
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Michael Farkouh
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | | | - Jacob Udell
- Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | - Amer Johri
- Queen's University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Echocardiogram and Vascular Lab, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Harry Rakowski
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - R Sacha Bhatia
- Women's College Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Han PJ, Tsai BT, Martin JW, Keen WD, Waalen J, Kimura BJ. Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography. Am J Med 2019; 132:227-233. [PMID: 30691553 DOI: 10.1016/j.amjmed.2018.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. METHODS For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. RESULTS In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. CONCLUSIONS A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.
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Affiliation(s)
- Paul J Han
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif
| | - Ben T Tsai
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Julie W Martin
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - William D Keen
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Jill Waalen
- Scripps Translational Science Research Institute, San Diego, Calif
| | - Bruce J Kimura
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif.
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Gupta T, Jahangir E, Gilliland Y, Lavie CJ, Shah S. Impact of appropriate use criteria for transesophageal echocardiograms on clinically meaningful care. Echocardiography 2018; 36:15-21. [DOI: 10.1111/echo.14189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Tripti Gupta
- Department of Internal Medicine; Ochsner Clinic Foundation; New Orleans Louisiana USA
| | - Eiman Jahangir
- Department of Cardiology; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - Yvonne Gilliland
- Department of Cardiology; Ochsner Clinic Foundation; New Orleans Louisiana USA
| | - Carl J. Lavie
- Department of Cardiology; Ochsner Clinic Foundation; New Orleans Louisiana USA
- Ochsner Clinical School, University of Queensland School of Medicine; Brisbane Queensland Australia
| | - Sangeeta Shah
- Department of Cardiology; Ochsner Clinic Foundation; New Orleans Louisiana USA
- Ochsner Clinical School, University of Queensland School of Medicine; Brisbane Queensland Australia
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36
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Stone JR, Lee L, Ward JP, Ward RP. High Prevalence of Clinically Important Echocardiographic Abnormalities in Patients with a Normal Electrocardiogram Referred for Transthoracic Echocardiography. J Am Soc Echocardiogr 2018; 31:926-932. [DOI: 10.1016/j.echo.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Indexed: 10/14/2022]
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37
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Kerley RN, O'Flynn S. A systematic review of Appropriate Use Criteria for transthoracic echocardiography: are they relevant outside the United States? Ir J Med Sci 2018; 188:89-99. [PMID: 29916134 DOI: 10.1007/s11845-018-1843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/07/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. Very few studies have assessed how medical centers overseas perform against AUC. Evidence is now emerging that inappropriate referral rates in Europe are similar to those reported in the US. OBJECTIVE This study systematically reviewed published evidence to identify (1) whether the 2011 AUC are applicable to medical centers outside the US (2) the level of adherence to the AUC across multiple centers, (3) the main factors which cause deviation from AUC, (4) any changes in referral rates since the publication of AUC, and (5) any factors and/or intervention strategies which promote adherence to AUC. METHODS AND RESULTS Electronic databases were systematically searched for papers related to AUC and cardiac imaging. Following screening and application of eligibility criteria, data was extracted from ten reports involving 8561 TTE studies. Classification rates were 99.5 and 98% for US studies and studies outside the US respectively. Overall, 7119 TTE studies were classified as appropriate (83.1%) of which 3724 were US referrals (84.7%) and 3395 originated outside the US (81.5%). Six of the included studies independently observed significantly more appropriate referrals among inpatients compared to outpatients (p < 0.001). US centers observed no significant difference in appropriate referral rates between physician specialties while one UK study showed cardiac surgeons ordered inappropriate TTEs more frequently than other specialties (p < 0.05). This review found no obvious trend in appropriate referral rates between 2012 and 2015 indicating no temporal change in physician ordering patterns. Only one educational interventional study met the author's criteria which showed that while intervention was effective during its implantation (26% reduction in TTEs ordered per day), TTE referral rates regressed to pre-intervention levels overtime. CONCLUSIONS In conclusion, the American guideline AUC are applicable to centers outside the US and their implementation across five international centers suggest almost 1 in 5 scans could be avoided.
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Affiliation(s)
- Robert N Kerley
- School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland.
| | - Siun O'Flynn
- School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland
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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.
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39
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Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database. Intensive Care Med 2018; 44:884-892. [DOI: 10.1007/s00134-018-5208-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 05/05/2018] [Indexed: 10/14/2022]
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40
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Lopes JR, Oliveira AC, Rios VG, Correia LCL. Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients. ACTA ACUST UNITED AC 2018; 51:e7413. [PMID: 29846434 PMCID: PMC5999063 DOI: 10.1590/1414-431x20187413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/06/2018] [Indexed: 01/08/2023]
Abstract
Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.
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Affiliation(s)
- J R Lopes
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
| | - A C Oliveira
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
| | - V G Rios
- Cardioclin, Conceição do Coité, BA, Brasil
| | - L C L Correia
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
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41
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Kaushal N, Wijeysundera HC, Connelly KA, Roifman I. Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings. J Magn Reson Imaging 2018; 49:e132-e138. [PMID: 29573034 DOI: 10.1002/jmri.26015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/02/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The rapid growth in cardiac imaging utilization has led to the development of appropriate use criteria (AUC) in an effort to control costs. Recently, cardiac MRI has developed into a valuable modality in the evaluation of cardiac disease. However, there are no studies examining the appropriate use of cardiac MRI in clinical practice. PURPOSE To determine the appropriate utilization of cardiac MRI in a large quaternary care institution and to compare percentages of appropriate utilization pre- and postpublication of the AUC document. We hypothesized that percentages of appropriate cardiac MRI utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant change in appropriate use pre- and post-AUC publication. STUDY TYPE Retrospective cohort study. POPULATION In all, 2032 consecutive patients undergoing cardiac MRI for the assessment of heart failure between 2012-2016. FIELD STRENGTH 1.5T. ASSESSMENT Data were collected and an appropriateness category was assigned for each cardiac MRI. STATISTICAL TESTS Rates of major cardiac risk factors were compared between those undergoing cardiac MRIs pre- and post-AUC using the chi-square and the Mann-Whitney tests for categorical and continuous variables, respectively. Appropriateness classification was compared pre- and post-AUC publication using the chi-square test. RESULTS There were no significant differences in the prevalence of major cardiovascular risk factors before and after publication of the AUC. 95.5% of all cardiac MRIs were appropriate based on the AUC. Further, there was a significant difference when comparing the appropriateness classification before and after publication of the AUC (P = 0.0003), potentially associated with annual cost savings of ∼$14.8 million. DATA CONCLUSION We report a very high percentage of appropriate use of cardiac MRI and a significant increase in the proportion of tests classified as appropriate after AUC publication. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e132-e138.
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Affiliation(s)
- Nishchay Kaushal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Idan Roifman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
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42
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Gunderson CG, Gromisch ES, Chang JJ, Malm BJ. Derivation of a Clinical Model to Predict Unchanged Inpatient Echocardiograms. J Hosp Med 2018; 13:164-169. [PMID: 29073315 DOI: 10.12788/jhm.2866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is one of the most commonly ordered tests in healthcare. Repeat TTE, defined as a TTE done within 1 year of a prior TTE, represents 24% to 42% of all studies. The purpose of this study was to derive a clinical prediction model to predict unchanged repeat TTE, with the goal of defining a subset of studies that are unnecessary. METHODS Single-center retrospective cohort study of all hospitalized patients who had a repeat TTE between October 1, 2013, and September 30, 2014. RESULTS Two hundred eleven of 601 TTEs were repeat studies, of which 78 (37%) had major changes. Five variables were independent predictors of major new TTE changes, including history of intervening acute myocardial infarction, cardiothoracic surgery, major new electrocardiogram (ECG) changes, prior valve disease, and chronic kidney disease. Using the β-coefficient for each of these variables, we defined a clinical prediction model that we named the CAVES score. The acronym CAVES stands for chronic kidney disease, acute myocardial infarction, valvular disease, ECG changes, and surgery (cardiac). The prevalence of major TTE change for the full cohort was 35%. For the group with a CAVES score of -1, that probability was only 5.6%; for the group with a score of 0, the probability was 17.7%; and for the group with a score ≥1, the probability was 55.3%. The bootstrap corrected C statistic for the model was 0.78 (95% confidence interval, 0.72-0.85), indicating good discrimination. CONCLUSIONS Overall, the CAVES score had good discrimination and calibration. If further validated, it may be useful to predict repeat TTEs that are unlikely to have major changes.
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Affiliation(s)
- Craig G Gunderson
- Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA. craig.gunderson@ va.gov
| | - Elizabeth S Gromisch
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychology, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - John J Chang
- Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Brian J Malm
- Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Cardiology, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Shaw LJ, Blankstein R, Jacobs JE, Leipsic JA, Kwong RY, Taqueti VR, Beanlands RSB, Mieres JH, Flamm SD, Gerber TC, Spertus J, Di Carli MF. Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2017; 10:e000017. [PMID: 29242239 PMCID: PMC5926771 DOI: 10.1161/hci.0000000000000017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.
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44
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Kerley RN, Thornton KP, Kelly RM, O'Flynn S. Appropriate use criteria for transthoracic echocardiography: Are they relevant to European centers? Echocardiography 2017; 35:17-23. [DOI: 10.1111/echo.13730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | | | - Siun O'Flynn
- School of Medicine; University College Cork; Cork Ireland
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45
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Romano MMD, Branco M, Moreira HT, Schmidt A, Kisslo J, Maciel BC. Appropriate use of echocardiography and relation to clinical decision making in both inpatients and outpatients in a developing country. Echocardiography 2017; 35:9-16. [PMID: 28994142 DOI: 10.1111/echo.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Use of echocardiography (echo) has exponentially increased in recent decades. Concerned about this scientific society developed appropriate use criteria (AUC). Clinical management still suffers geographical variations, and no objective data are available about echo AUC in developing countries. We aimed to evaluate (1) the appropriateness of referrals and (2) their relation to changes in clinical decision management. METHODS Prospective analysis of referrals from January to December 2014. Appropriateness and endpoints analyzed in different time points from medical archives. ENDPOINTS (1) change in the diagnosis, (2) indication for another method to complete the diagnosis, (3) change in clinical treatment, (4) indication for a treatment intervention, or (5) no change in management. Descriptive statistical analysis, Fisher's or chi-square tests, and Cox regression used as appropriate (significance if P < .05). RESULTS One thousand one hundred referrals were analyzed (55.5 ± 16.1 years, 44.6% male). 80.5% of referrals were appropriate (A), 11.2% "Rarely Appropriate" (RA), and 8.3% "May Be Appropriate" (MBA). Proportion of (A) did not differ between modalities (TTE-80.5% vs TEE-87.7% vs STR-81.2%, P = .67). (A) referrals were more related to clinical decision than (RA)+(MBA) (38.9% [A] vs 15% [RA]+[MBA], P < .001). The most frequent clinical indications of (RA) and (MBA) TTE were reevaluation of ventricular function without clinical change (AUC 10 and 11) and search of infectious endocarditis when low clinical probability (53). CONCLUSIONS In a developing country, appropriateness of echo was similar to the United States and Europe. However, a significant proportion of referrals were still (RA) or (MBA), with no effect in clinical management. Controlling referrals 10, 11, and 53 can optimize echo use in developing countries.
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Affiliation(s)
- Minna Moreira Dias Romano
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Marina Branco
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Henrique Turin Moreira
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - André Schmidt
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Joseph Kisslo
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Benedito Carlos Maciel
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
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46
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Hua A, McCaughan V, Wright M, Zaidi A, Wright J, Azam A, Bhattacharyya S, Stock L, Lloyd G, Bhattacharyya S. Appropriateness, diagnostic value, and outcomes of repeat testing following index echocardiography. Echocardiography 2017; 35:24-29. [PMID: 28994195 DOI: 10.1111/echo.13726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS Emergency admission to hospital is associated with an economic burden and mortality. Echocardiography is often the first-line cardiovascular imaging investigation. Repeat testing is common; however, there are sparse data on the prevalence, appropriateness, or outcome of repeat testing. METHODS We performed an electronic database search for patients with emergency admissions to our institution in February 2015. An electronic patient record review of inpatient echocardiograms was undertaken. Indications for echocardiography were classified as appropriate, may be appropriate, or rarely appropriate. One-year follow-up for repeat testing and mortality was investigated. RESULTS A total of 409 of 2306 (17.7%) unplanned/emergency admissions underwent inpatient echocardiography. Abnormalities were identified in 165/409 (40.3%) of these patients; 154 of 409 (37.7%) had a repeat echocardiogram within the next year. Rarely appropriate indications for echocardiography occurred in 51 (33%) of repeat vs 53 (16%) of index echocardiograms, P < .0001. Repeat testing was associated with a change in findings in 17/154 (11%) patients overall. All of whom had an abnormal index echocardiogram and had an appropriate indication. There was no difference in mean survival time between patients who underwent repeat and those who only underwent a single index echocardiogram (310 days vs 327 days), P = .34. CONCLUSION Inpatient echocardiography in emergency hospital admissions identifies clinically important pathology. Repeated testing is common within 1 year of hospital admission. New diagnostic findings occurred in 11% of patients and only in patients with appropriate studies and an abnormal index echocardiogram. Identification of methods to reduce repeat testing and implement appropriateness criteria is warranted.
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Affiliation(s)
- Alina Hua
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Vincent McCaughan
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Matthew Wright
- University College London Hospital, London, United Kingdom
| | - Abbas Zaidi
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
| | - Jessica Wright
- University College London Hospital, London, United Kingdom
| | - Aishah Azam
- University College London Hospital, London, United Kingdom
| | | | - Lisanne Stock
- University College London Hospital, London, United Kingdom
| | - Guy Lloyd
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
| | - Sanjeev Bhattacharyya
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
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47
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Singh A, Ward RP. Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare. Curr Cardiol Rep 2017; 18:93. [PMID: 27553788 DOI: 10.1007/s11886-016-0758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.
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Affiliation(s)
- Amita Singh
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA.
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48
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Sachdeva R, Kelleman MS, McCracken CE, Campbell RM, Lai WW, Lopez L, Stern KW, Welch E, Douglas PS. 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.e2. [DOI: 10.1016/j.echo.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Indexed: 01/12/2023]
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49
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Tanguturi VK, Hidrue MK, Picard MH, Atlas SJ, Weilburg JB, Ferris TG, Armstrong K, Wasfy JH. Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006495. [PMID: 28774932 DOI: 10.1161/circimaging.117.006495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics. METHODS AND RESULTS We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers. CONCLUSIONS We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.
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Affiliation(s)
- Varsha K Tanguturi
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Michael K Hidrue
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Michael H Picard
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Steven J Atlas
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Jeffrey B Weilburg
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Timothy G Ferris
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Katrina Armstrong
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Jason H Wasfy
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.).
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50
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Samad Z, Douglas PS. Vigilance in Mitral Regurgitation: Variation and the Way Forward. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006799. [PMID: 28774933 DOI: 10.1161/circimaging.117.006799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zainab Samad
- From the Division of Cardiology, Department of Medicine, Duke University, Durham, NC (Z.S., P.S.D.); and Duke Clinical Research Institute, Durham, NC (P.S.D.)
| | - Pamela S Douglas
- From the Division of Cardiology, Department of Medicine, Duke University, Durham, NC (Z.S., P.S.D.); and Duke Clinical Research Institute, Durham, NC (P.S.D.).
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