Ritu Sachdeva1, Joseph Allen2, Oscar J Benavidez3, Robert M Campbell4, Pamela S Douglas5, Benjamin W Eidem6, Lara Gold2, Michael S Kelleman4, Leo Lopez7, Courtney E McCracken4, Kenan W D Stern8, Rory B Weiner3, Elizabeth Welch7, Wyman W Lai9. 1. Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia. Electronic address: sachdevar@kidsheart.com. 2. American College of Cardiology, Washington, DC. 3. Massachusetts General Hospital, Boston, Massachusetts. 4. Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia. 5. Duke University, Durham, North Carolina. 6. Mayo Clinic, Rochester, Minnesota. 7. Miami Children's Hospital, Miami, Florida. 8. Children's Hospital at Montefiore, New York, New York. 9. Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York.
Abstract
BACKGROUND: Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability. OBJECTIVES: This study sought to determine the appropriateness of TTE as currently performed in pediatric cardiology clinics, diagnostic yield of TTE for various AUC indications, and any gaps in the AUC document. METHODS: Data were prospectively collected from patients undergoing initial outpatient TTE in 6 centers. TTE indications (appropriate [A], may be appropriate [M], or rarely appropriate [R]) and findings (normal, incidental, or abnormal) were recorded. RESULTS: Of the 2,655 studies ordered by 102 physicians, indications rated A, M, and R were found in 1,876 (71%), 316 (12%), and 319 studies (12%), respectively, and 144 studies (5%) were unclassifiable. Twenty-four of 113 indications (21%) were not used. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for 75% of indications rated R. Pathologic murmur had the highest yield of abnormal findings (40%). Odds of an abnormal finding in an A or M TTE were 6 times that of R (95% confidence interval [CI]: [2.8 to 12.8]). Abnormal findings were more common in patients <1 year of age than in those >10 years of age (odds ratio: 6.4; 95% CI: 4.7 to 8.7). Age was a significant predictor of an abnormal finding after adjusting for indication and site (p < 0.001). CONCLUSIONS: Most TTEs ordered in pediatric cardiology clinics were for indications rated A. AUC ratings successfully stratified indications based on the yield of abnormal findings. This study identified differences in the yield of TTE based on patient age and most common indications rated R. These findings should inform quality improvement efforts and future revisions of the AUC document.
BACKGROUND: Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability. OBJECTIVES: This study sought to determine the appropriateness of TTE as currently performed in pediatric cardiology clinics, diagnostic yield of TTE for various AUC indications, and any gaps in the AUC document. METHODS: Data were prospectively collected from patients undergoing initial outpatient TTE in 6 centers. TTE indications (appropriate [A], may be appropriate [M], or rarely appropriate [R]) and findings (normal, incidental, or abnormal) were recorded. RESULTS: Of the 2,655 studies ordered by 102 physicians, indications rated A, M, and R were found in 1,876 (71%), 316 (12%), and 319 studies (12%), respectively, and 144 studies (5%) were unclassifiable. Twenty-four of 113 indications (21%) were not used. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for 75% of indications rated R. Pathologic murmur had the highest yield of abnormal findings (40%). Odds of an abnormal finding in an A or M TTE were 6 times that of R (95% confidence interval [CI]: [2.8 to 12.8]). Abnormal findings were more common in patients <1 year of age than in those >10 years of age (odds ratio: 6.4; 95% CI: 4.7 to 8.7). Age was a significant predictor of an abnormal finding after adjusting for indication and site (p < 0.001). CONCLUSIONS: Most TTEs ordered in pediatric cardiology clinics were for indications rated A. AUC ratings successfully stratified indications based on the yield of abnormal findings. This study identified differences in the yield of TTE based on patient age and most common indications rated R. These findings should inform quality improvement efforts and future revisions of the AUC document.
Authors: Markus S Renno; A Nicole Lambert; Prince Kannankeril; David P Johnson; David A Parra Journal: Pediatr Cardiol Date: 2020-01-14 Impact factor: 1.655