A Quality Improvement Initiative for Echocardiogram Ordering Patterns in an Academic Hospital

Background Appropriate Use Criteria (AUC) for echocardiography are a useful tool to deliver quality healthcare. Our quality-based interventional study was designed to assess the trends in appropriate utilization rates for echocardiography in our institution and improve adherence to the AUC criteria for transthoracic echocardiograms (TTE). Methodology A prospective, time series analysis was conducted at the Upstate University Hospital for the months of July 2019 and August 2020. A chart analysis was performed on 620 consecutive inpatients who underwent TTE for the month of July 2019. We assessed the trends of the appropriate ordering of TTEs. We then updated our order form incorporating the 42 most common appropriate indications. A post-intervention chart analysis was performed on all inpatient TTEs ordered for the month of August 2020 (n = 410). The appropriateness of the TTE for the entire group was determined based on the true indication per chart review. The primary outcome was the proportion of appropriate and inappropriate TTEs ordered. Secondary outcomes included assessing for concordance between the indication on the order requisition form and by chart review. A p-value <0.05 was considered significant. Results Using the 2011 AUC for the entire group, 81% of the pre-intervention TTEs and 79.5% of the post-intervention TTEs were appropriate (p = 0.55). There was a statistically significant reduction in the number of discordant TTE orders before and after the intervention (p < 0.01). In addition, we noted increased appropriateness of TTEs in the concordant group both pre and post-intervention. Conclusions Our study demonstrates a significant increase in the concordance between the TTE order sheet and actual indication per chart review with the intervention. This can translate into improved scanning and physician reading quality and time, thereby increasing focus on areas of interest according to the true indication. There was no significant increase in the appropriate TTEs ordered.

Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review

OBJECTIVE

The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors.

DESIGN/METHODS

A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947-November 2021) and EMBASE (1947-November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2.

MAIN OUTCOME MEASURES

Sensitivity, specificity and likelihood ratios (LRs).

RESULTS

We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators.

CONCLUSION

Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD.

PROSPERO REGISTRATION NUMBER

CRD42018091675.

The Rate of Appropriate Adult Transthoracic Echocardiogram at King Abdulaziz University Hospital Based on Appropriate Use Criteria of 2011, 2017, and 2019

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.

Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE)

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%.

A systematic review of pocket-sized imaging devices: small and mighty?

Introduction

Hand-held imaging devices are widely used in clinical practice and are a useful tool. There is no published review examining the diagnostic parameters achieved with these devices in clinical practice.

Methods

We searched three online medical literature databases (PubMed, EMBASE and MEDLINE) for all literature published up until January 2018. We selected studies that (1) were conducted in the adult population; (2) used a truly hand-held device; (3) featured sensitivities and/or specificities on the use of the hand-held scanner. We extracted and summarised the diagnostic metrics from the literature.

Results

Twenty-seven articles were excluded from the initial 56 relevant articles, as the device featured was not truly hand-held. Ultimately a total of 25 studies were analysed. Sixteen studies were carried out by experienced users, seven by users with little previous experience and two studies by nurses. High diagnostic parameters were achieved by all three groups when scanning cardiac pathology and intra-abdominal structures. Training of non-expert users varied, taking a mean of 21.6 h. These hand-held devices can change diagnoses at the bedside and be used as gate-keepers to formal echocardiography. Individual studies show them to be cost-effective.

Conclusion

Hand-held echocardiography is a useful tool in the hands of experts and novices alike. Studies conducted are highly heterogeneous making it difficult to pool data for the diagnostic metrics. Further studies with rigorous methodology are needed to evaluate the true diagnostic potential in the hands of non-experts and in the community as well as to validate training protocols.

A systematic review of Appropriate Use Criteria for transthoracic echocardiography: are they relevant outside the United States?

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.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BACKGROUND

Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

OBJECTIVE

To identify overuse and underuse of diagnostic tests in primary care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

RESULTS

We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

CONCLUSIONS

There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy.

PROSPERO REGISTRATION NUMBER

CRD42016048832.

Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association

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.

Appropriate use of echocardiography and relation to clinical decision making in both inpatients and outpatients in a developing country

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.

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

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.

Appropriate use criteria for echocardiography in the Netherlands

Introduction

Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way.

Methods

All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively).

Results

Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper.

Conclusions

Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-017-0960-9) contains supplementary material, which is available to authorized users.

Usefulness of Hand-Held Ultrasonography as a Gatekeeper to Standard Echocardiography for "Rarely Appropriate" Echocardiography Requests

Adoption of appropriate use criteria has not had a major impact on the frequency of "rarely appropriate" tests, with the rarely appropriate tests rate remaining at ∼20% in most institutions. We sought whether access to hand-held ultrasound (HHU) could be an alternative means of reducing rarely appropriate requests. We compared 2 approaches to rarely appropriate requests; "standard transthoracic echocardiography" (SE) as requested (control) and HHU as a gatekeeper (HHU). Patients were followed up for 6 months and assessed for end points including time until scan, repeat echocardiography/cost of either strategy, new major pathology, and change in management. The most common rarely appropriate requests in both groups were assessment of infective endocarditis without positive blood cultures and precordial murmur evaluation in absence of any other signs or symptoms of cardiovascular disease. The groups had comparable age, gender, requesting physician, and inpatient versus outpatient distribution. HHU led to a 59% reduction in rarely appropriate requests requiring SE. HHU significantly reduced time to decision for inpatients (0 [interquartile range 0, 1] vs 2 days [interquartile range 1, 4], p <0.001) and total cost of echocardiography (109 ± 86 vs 181 ± 37 USD, p <0.001). New major pathology was identified in 29% and 23% of HHU and SE, respectively. There was no difference with respect to change in management. In conclusion, HHU can be an effective gatekeeper to SE for rarely appropriate echocardiograms, reducing time to echocardiography and cost while satisfying the referring physician and avoiding repeat requests for SE. HHU provides a safety net that identifies potential important findings in rarely appropriate requests.

Impact of a structured referral algorithm on the ability to monitor adherence to appropriate use criteria for transthoracic echocardiography

BACKGROUND

Many free-form-text referral requisitions for transthoracic echocardiography (TTE) provide insufficient information to adequately evaluate their adherence to Appropriate Use Criteria (AUC). We developed a structured referral requisition algorithm based on requisition deficiencies identified retrospectively in a derivation cohort of 1303 TTE referrals and evaluated the performance of the algorithm in a consecutive series of cardiology outpatient referrals.

METHODS

The validation cohort comprised 286 consecutive TTE outpatient cardiology referrals over a 2-week period. The relevant AUC indication was identified from information extracted from the free-form-text requisition. The structured referral algorithm was applied prospectively to the same cohort using information from the free-form-text requisition, electronic medical record and ordering clinicians. Referrals were classified as appropriate, uncertain, non-adherent (inappropriate) or unclassifiable based on the American College of Cardiology Foundation 2011 AUC.

RESULTS

Only 28.7 % of free-form-text requisitions provided adequate information to identify the relevant AUC indication, as compared to 94.4 % of referrals using the structured referral algorithm (p < 0.001). The structured algorithm improved identification in the AUC categories of general evaluation of cardiac structure/function (100 % vs. 43.0 %, p < 0.001); valvular function (100 % vs. 23.0 %, p < 0.001); hypertension, heart failure or cardiomyopathy (100 % vs. 20.3 %, p < 0.001); and adult congenital heart disease (100 % vs. 0 %, p < 0.001). By applying the algorithm, the number of identifiable non-adherent studies increased from 2.6 to 10.4 % (p <0.001).

CONCLUSIONS

Use of a structured TTE referral algorithm, as opposed to a free-form-text requisition, allowed the vast majority of referrals to be monitored for AUC adherence and facilitated the identification of potentially inappropriate referrals.

Appropriate Use Criteria in Echocardiography: An Observational Institutional Study with the Perspective of a Quality Improvement Project

BACKGROUND

Appropriate use criteria (AUC) in echocardiography are essential tools for aligning the indications of echocardiography with the best clinical standards, improving clinical outcome, restraining abuse, and preserving health-care resources.

OBJECTIVES

The aim of this study was to ascertain the AUC for transthoracic echocardiography in a university hospital and create a quality improvement project (QIP).

METHODS

The assessment of 501 inpatients who received transthoracic cardiac echo was conducted according to the 2011 AUC report. Indications were classified as appropriate, uncertain, or inappropriate, and patients not matching any of the abovementioned divisions were grouped in the nonfitting category.

RESULTS

Of the 501 eligible patients, 374 patients (74.66%) were in the appropriate group, 85 patients (16.96%) in the inappropriate group, 20 patients (3.99%) in the uncertain group, and 22 patients (4.39%) in the nonfitting category.

DISCUSSION

Interpretation and analysis of the obtained results are presented, along with the results of many comparable studies; moreover, a QIP was set up accordingly.

CONCLUSION

AUC are useful to assess local practice, preserve health-care resources, and improve clinical outcome.

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

Background

Responding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple imaging modalities in an inpatient environment.

Methods

A retrospective study of the appropriateness of cardiac tests ordered by the inpatient General Internal Medicine (GIM) and Cardiology services at three Canadian academic hospitals was conducted over two one-month periods. Cardiac tests characterized were transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), single-photon emission tomography myocardial perfusion imaging (SPECT), and diagnostic cardiac catheterization.

Results

Overall, 553 tests were assessed, of which 99.8 % were classifiable by AUC. 91 % of all studies were categorized as appropriate, 4 % may be appropriate and 5 % were rarely appropriate. There were high rates of appropriate use of all modalities by GIM and Cardiology throughout. Significantly more appropriate diagnostic catheterizations were ordered by Cardiology than GIM (93 % vs. 82 %, p = <0.01). Cardiology ordered more appropriate studies overall (94 % vs. 88 %, p = 0.03) but there was no difference in the rate of rarely appropriate studies (3 % vs. 6 %, p = 0.23).

Conclusion

The ACCF AUC captured the vast majority of clinical scenarios for multiple cardiac imaging modalities in this multi-centered study on Cardiology and GIM inpatients in the acute care setting. The rate of appropriate ordering was high across all imaging modalities. We recommend further work towards improving appropriate utilization of cardiac imaging resources focus on the out-patient setting.

Are valve clinics a sound investment for the health service? A cost-effectiveness model and an automated tool for cost estimation

BACKGROUND

Valve disease is using up an important, growing proportion of the resources allocated for healthcare. Clinical care is often suboptimal and while multidisciplinary clinics are the 'gold standard', their adoption has been patchy and inhomogeneous.

METHODS

We hypothesised that adoption of valve clinics can deliver financial savings and set out to estimate differences in cost between a standard model in which the cardiologist sees every case and a multidisciplinary model in which some cases are devolved to sonographer-led or nurse-led clinics, assuming usage of various tests in accordance with practice at our institutions and to published data. We developed a tool that allows the modelling of limitless permutations in order to assess costs.

RESULTS

Seeing 100 new patients in a valve clinic is more expensive than seeing them in the conventional set-up (excess cost £2700, $4252). Follow-up of both patients with native valve disease (maximal savings/100 patients-£5166, $8135) and with operated valves (maximal savings/100 patients-£5090, $8015) is cheaper in a valve clinic than in a general cardiology clinic and the savings offset the increased cost of seeing new patients in the valve clinic.

CONCLUSIONS

The costing implications of valve clinics need to be worked out carefully. Our analysis suggests that important savings in healthcare costs could be achieved by their adoption. Clarifying the economic implications of this new model of care should become one of the priorities for the 'heart valve community'.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.