Discrepancy identified between appropriateness, clinical effect of transthoracic echocardiography

In a new report, nine in 10 transthoracic echocardiographic procedures were deemed appropriate under 2011 criteria; however, less than one-third of procedures resulted in an active change in care.

The findings led researchers to call for “a better method to optimize transthoracic echocardiography (TTE) utilization to use limited health care resources efficiently while providing high-quality care.”

Susan Matulevicius, MD, and colleagues conducted a retrospective review of all TTEs ordered in April 2011 (n=535, 58.7% women) at the University of Texas Southwestern Medical Center. The study goal was to examine the relationship between the appropriateness of a TTE and its clinical effect.

Susan Matulevicius

“Transthoracic echocardiography accounts for almost half of all cardiac imaging services. Appropriate use criteria (AUC) for echocardiography were developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate by AUC. However, the associations among TTE, AUC and their clinical impact have not been well explored,” according to background information in the study.

For this analysis, reviewers who were unaware of TTE results classified the procedure as appropriate, inappropriate or uncertain as defined by the 2011 AUC established by the American College of Cardiology Foundation in collaboration with other societies. To determine clinical effect, a different set of reviewers unaware of the appropriateness classification categorized each TTE result and subsequent course of treatment as active change in care, continuation of current care or no change in care. Active change in care was defined as escalation or de-escalation in care resulting from TTE including medication changes, subspecialty consultation, surgery or other invasive procedures, diagnostic testing, transfer to a different level of care, and cancellation of a previously planned procedure.

Appropriateness of procedures

Based on 2011 AUC criteria, the reviewers classified 91.8% of the TTEs as appropriate, 4.3% inappropriate and 3.9% uncertain. However, only 31.8% of the TTEs resulted in an active change in care, 46.9% resulted in continuation of current care and 21.3% resulted in no change in care.

There was no major difference between appropriate and inappropriate TTEs in the proportion of TTEs leading to active change in care (32.2% vs. 21.7%, P=.29).

TTEs ordered by cardiologists were associated with a lower proportion of studies that resulted in no change in care (12.6%) when compared with other specialties such as pulmonary/critical care (39%; P<.001) and surgery (31.5%; P=.004).

William Armstrong

Further diagnostic testing (29.4%) and subspecialty consultation (25.9%) were the most common active changes.

Older age (P=.003) and inpatient study setting (P<.001) were identified as factors associated with no change in care.

“These data suggest that AUC for TTE have not fulfilled one of its anticipated results, to have ‘a significant impact on physician decision-making,’ and they did not curb the growth of TTE use since publication,” the researchers wrote. “The discrepancy between appropriateness and clinical impact is striking and suggests that the AUC as currently implemented are unlikely to facilitate optimal use of TTE.”

One option to improve the discrepancy between appropriateness and clinical effect, they said, is “to incorporate a consensus opinion of ‘necessary’ into the categorization of AUC” for TTE.

Kim A. Eagle

A call for greater efficiency

In a related editorial, William Armstrong, MD, and Kim A. Eagle, MD, both cardiologists at the University of Michigan Medical Center, said this study “points the way for further prospective studies looking at the impact of echocardiography and how it affects physician decision making.”

“The degree to which these outcomes are exclusively shortcomings of the AUC is debatable but raises concerns that further modifications — and probably physician education — are necessary to achieve a more efficient use of echocardiography and conserve resources,” they wrote.

For more information:

Armstrong W. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.7273.

Matulevicius SA. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.8972.

Disclosure: The researchers and editorial authors report no relevant financial disclosures.