Factors Influencing Pediatric Outpatient Transthoracic Echocardiography Utilization Before Appropriate Use Criteria Release: A Multicenter Study

Appropriateness of cardiovascular computed tomography and magnetic resonance imaging in patients with conotruncal defects

BACKGROUND

To promote the rational use of cardiovascular imaging in patients with congenital heart disease, the American College of Cardiology developed Appropriate Use Criteria (AUC), but its clinical application and pre-release benchmarks have not been evaluated. We aimed to evaluate the appropriateness of indications for cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) in patients with conotruncal defects and to identify factors associated with maybe or rarely appropriate (M/R) indications.

METHODS

Twelve centers each contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. To incorporate patient characteristics and center-level effects, a hierarchical generalized linear mixed model was used.

RESULTS

Of the 1753 studies (80% CMR, and 20% CCT), 16% were rated M/R. Center M/R ranged from 4 to 39%. Infants accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age <1 year (OR 1.90 [1.15-3.13]), truncus arteriosus (vs. tetralogy of Fallot, OR 2.55 [1.5-4.35]), and CCT (vs. CMR, OR 2.67 [1.87-3.83]). None of the provider- or center-level factors reached statistical significance in the multivariable model.

CONCLUSIONS

Most CMRs and CCTs ordered for the follow-up care of patients with conotruncal defects were rated appropriate. However, there was significant center-level variation in appropriateness ratings. Younger age, CCT, and truncus arteriosus were independently associated with higher odds of M/R rating. These findings could inform future quality improvement initiatives and further exploration of factors resulting in center-level variation.

Implementation of Appropriate Use Criteria for Transthoracic Echocardiography in Follow up Care of Pediatric Patients with Congenital Heart Disease

BACKGROUND

Indications for transthoracic echocardiography (TTE) from the 2020 Appropriate Use Criteria (AUC) for congenital heart disease (CHD) were incorporated into our electronic ordering system as a clinical decision support tool. The purpose of this study was to evaluate TTE utilization and factors affecting appropriateness of TTE orders during follow-up care of patients with CHD.

METHODS

All TTEs performed during follow-up clinic visits from 5/1/2020 to 11/30/2020 were included. TTE indications were rated appropriate (A), may be appropriate (M), or rarely appropriate (R) based on the AUC, and unclassifiable if indication was not in the document but related to included lesions. CHD was graded as simple, moderate, and complex based on Bethesda classification. Logistic regression was used to determine association of ratings with patient age, insurance status, CHD complexity, clinician experience and specialty.

RESULTS

Of the 5158 studies, 3979 (77.2%) were for CHD included in the AUC document, 322 (8%) were unclassifiable, 37 (0.7%) for CHD not in the document, and 1142 (22.1%) for non-CHD indications. Of the 3657 TTEs to which AUC ratings could be applied, 95.6% were A, 2.4% M, and 2.0% R. The highest utilization of TTE was for follow-up of ventricular septal defects, left ventricular outflow tract obstruction, and single ventricles; 46% for unrepaired CHD; 78% for routine surveillance and the remaining for a change in clinical status. On multivariable analysis, the only significant factor associated with M/R ratings was simple CHD [OR 11.58 (95% CI 5.36 - 24.98), p<0.001].

CONCLUSIONS

Three-quarters of the TTEs ordered during follow-up care in pediatric cardiology clinics are for indications related to CHD. Most TTEs for follow-up of CHD were for routine surveillance and indications rated A. TTE orders for M/R ratings were associated with simple CHD. Though the 2020 AUC document successfully stratifies majority of indications related to CHD, future documents should consider the unclassifiable CHD indications and the non-CHD indications.

Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization

BACKGROUND

Concern exists over exponential growth in cardiac imaging in adults, but there is paucity of such data for cardiac imaging trends in pediatric patients. The aims of this study were to determine temporal trends in the use of noninvasive cardiac imaging and compare these with trends in the use of noncardiac imaging and to identify factors influencing those trends using the Pediatric Health Information Service database.

METHODS

Pediatric inpatient encounter data from January 2004 to December 2017 at 35 pediatric hospitals were extracted from the Pediatric Health Information Service database. Temporal imaging utilization trends in cardiac and noncardiac ultrasound or echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) were assessed using linear mixed-effects models. Models were adjusted for case-mix index, complex chronic conditions, patient age, length of stay, payer source, and cardiac surgical volume.

RESULTS

A total of 5,869,335 encounters over 14 years were analyzed (median encounters per center per year, 11,411; median patient age, 4 years; median length of stay, 3 days). From 2004 to 2017, the rates of pediatric inpatient cardiac and noncardiac ultrasound and MRI increased, whereas the rate of noncardiac CT decreased. Cardiac CT use increased beginning in 2014 (+0.264 cardiac CT encounters per 1,000 encounters per year), surpassing the rate of rise of cardiac MRI. Case-mix index, cardiac surgical volume, and payer source affected the largest number of imaging trends.

CONCLUSIONS

Among pediatric inpatients, utilization of cardiac and noncardiac ultrasound and MRI has steadily increased. Noncardiac CT use declined and cardiac CT use increased after 2014. Factors influencing imaging trends include case-mix index, cardiac surgical volume, and payer source. This study lays a foundation for investigations of imaging-related resource utilization and outcomes among pediatric inpatients.

Impact of Clinician Engagement on Implementation of the Pediatric Echocardiography Appropriate Use Criteria

We sought to determine whether awareness of the pediatric appropriate use criteria (AUC) affected transthoracic echocardiogram (TTE) ordering by cardiologists; evaluate for differences in classification of an encounter's AUC clinical scenario by investigator chart review compared with clinicians at the time of the encounter; and assess TTE yield by appropriateness rating. AUC clinical scenario(s) were assigned to patients without prior TTE by investigator chart review of visits in 2014 (n = 209) and 2016 (n = 199), and by clinician classification in 2016 (n = 671). Investigators documented TTE utilization and findings. Between 2014 and 2016, TTE utilization decreased from 54 to 33% (p < 0.001) of "rarely appropriate" (R) encounters, resulting in a decrease in overall TTE utilization from 73 to 55% of encounters (p < 0.001). There was only moderate agreement of AUC appropriateness by investigator chart review and clinician classification (κ = 0.533, p < 0.001). Abnormal TTE findings were detected in 18.7% of R encounters, with 21 of 24 abnormalities in infants younger than 4 months presenting with murmur. A decrease in TTE utilization for R encounters may represent a change in practice from increased awareness of the AUC. AUC scenario classification by clinicians at the time of the encounter could be superior to chart review. TTE abnormalities may be missed in infants younger than 4 months of age when evaluated for murmurs with the AUC.

Comparison of Initial Pediatric Outpatient Echocardiogram Indications between Community and Academic Practice

OBJECTIVE

To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital.

STUDY DESIGN

Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings.

RESULTS

Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008).

CONCLUSION

The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.

Application of pediatric Appropriate Use Criteria for initial outpatient evaluation of asymptomatic patients with abnormal electrocardiograms

INTRODUCTION

In the pediatric Appropriate Use Criteria (AUC), abnormal electrocardiogram (ECG) in an asymptomatic patient has been rated as an "Appropriate" indication for transthoracic echocardiogram (TTE). We hypothesized that the yield of abnormal findings on TTE for this indication will be low.

METHODS

All asymptomatic patients (≤ 18 years) from January 1, 2015 to December 31, 2017 who underwent initial outpatient evaluation at our center and had a TTE ordered for an abnormal ECG, were included. Clinic records were reviewed to obtain ECG and TTE findings.

RESULTS

Of the 199 study patients, 13 (6.5%) had abnormal findings. Incomplete right bundle branch block (IRBBB) had the highest yield of abnormal TTE findings (7/28), with secundum atrial septal defect being the most common (5/7); (Odds ratio (OR) compared to other ECG findings 9.2, 95% CI (2.8-29.9), P < .001). OR further increased to 14.6, 95% CI (3.1-68.0), P < .001 when either IRBBB, right axis deviation, or right ventricular hypertrophy were present. Left ventricular hypertrophy on ECG had only one incidental abnormality on TTE, while ST segment changes, left axis deviation, right/left atrial enlargement, premature atrial/ventricular contractions, ectopic atrial rhythm, sinus bradycardia/pause, preexcitation, low-grade atrioventricular block, and junctional rhythm did not yield abnormal TTEs.

CONCLUSIONS

The yield of abnormal findings on TTE when performed for the AUC indication for an abnormal ECG in asymptomatic pediatric patients is low except when performed for ECG abnormalities suggestive of right heart disease such as IRBBB, right axis deviation, or right ventricular hypertrophy. Future revisions of the AUC document could consider further stratification of this indication and corresponding appropriateness ratings based on ECG findings rather than combining into one broad category.