Appropriateness and diagnostic yield of inpatient pediatric echocardiograms

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Appropriateness and subsequent management of inpatient echocardiograms: An evaluation of low value care

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.

A qualitative assessment of pediatric cardiology core content: Comments from Kentucky trainees, pediatricians, and pediatric cardiologists

OBJECTIVE

The 2016 American Board of Pediatrics (ABP) content outline is comprehensive, including more than 50 cardiology-specific objectives within eight content areas. This study complements the quantitative analysis of a Kentucky-wide survey of trainees, pediatricians, and pediatric cardiologists asking them to identify "most important" cardiology content by analyzing their open-ended comments about "what should be added" and "why?" within these eight categories.

DESIGN, METHODS, OUTCOME MEASURES

This cross-sectional study used an original, online survey instrument based on the 2016 ABP cardiology-specific objectives. We began an initial analysis of the qualitative data using Pandit's version of Glaser and Strauss Grounded theory (constant comparison). However, upon finding an abundance of comments focused on Diagnosis, we proceeded with a secondary analysis that further categorized Diagnosis comments into three themes aligned with Bloom's taxonomy. Additional comments focused on Management and clustered into Emergent/Acute Care (Resuscitation); Short-term Care (Inpatient); and Longitudinal Care (Outpatient).

RESULTS

Of the 136 respondents, 23 (17%) were residents, 15 (11%) fellows, 85 (62%) pediatricians, and 13 (10%) pediatric cardiologists with 80% of attendings having faculty/gratis faculty status. The open-ended questions "what needs to be added" and "why" generated 93 comments; 60 of which focused on Diagnosis; further classified as Recognize (16), Differentiate (12), and Evaluate (32). Management comments were related to acuity and care setting, grouped as Emergent/Acute Care (Resuscitation) [10]; Short-term Care (Inpatient) [6]; and Longitudinal Care (Outpatient) [17].

CONCLUSIONS

The 93 comments analyzed for this article showed a distinct preference for all respondents, trainees, pediatricians, and cardiologists alike, to value the addition of diagnostic skills with emphasis in the "evaluate" skill set as important cardiology curricular content beyond that included in the 2016 ABP cardiology-specific objectives. Responses could be used to provide practical guidance for curriculum design and reform.

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

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.

[Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]

INTRODUCTION

Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy.

PATIENTS AND METHOD

Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis.

RESULTS

A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy.

CONCLUSION

To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.

Knowledge of Appropriate Outpatient Pediatric Echocardiogram Ordering in Primary Care Physicians and Trainees

Appropriate Use Criteria (AUC) for the initial use of outpatient pediatric echocardiography were established to aid all clinicians in the evaluation of children with possible heart disease, and limit low diagnostic yield studies. We sought to (1) assess PCPs' and trainees' awareness of the AUC document; (2) compare their knowledge of appropriate echocardiogram ordering with that of pediatric cardiologists; and (3) identify additional medical and nonmedical factors affecting PCP echocardiogram ordering. An online survey with clinical scenarios derived from the AUC guidelines was distributed to PCPs and trainees in Arkansas, and pediatric cardiologists from Arkansas Children's Hospital and Cincinnati Children's Hospital Medical Center. Respondents were also asked to rate whether additional medical and nonmedical factors have "no," "mild," "moderate," or "major" impact on PCP echocardiogram ordering. Survey data were collected from 148 respondents. Awareness of the AUC was significantly lower in PCPs (21.4%) and trainees (14%) than in pediatric cardiologists (90.5%, p <0.001). For all rarely appropriate clinical scenarios, cardiologists had stronger agreement with the AUC document (90.9%) than did the PCP group (50.3%) and trainees (53.3%, p <0.001). The strongest additional factors affecting PCP echocardiogram ordering were parental anxiety, difficulty distinguishing innocent from pathologic murmurs, and legal implications of a missed diagnosis. In conclusion, PCPs and trainees are largely unaware of the existence of the pediatric echocardiogram AUC. Educational strategies to improve appropriate echocardiogram ordering should address not only increasing awareness of AUC, but also other factors affecting decision-making.