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Original Investigation |

Appropriate Use and Clinical Impact of Transthoracic Echocardiography

Susan A. Matulevicius, MD1; Anand Rohatgi, MD, MSCS1; Sandeep R. Das, MD, MPH1; Angela L. Price, MD1; Andres deLuna, MD1; Sharon C. Reimold, MD1
[+] Author Affiliations
1Department of Medicine, The University of Texas Southwestern Medical Center, Dallas
JAMA Intern Med. 2013;173(17):1600-1607. doi:10.1001/jamainternmed.2013.8972.
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Importance  Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. 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.

Objectives  To describe the proportion of TTEs that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by AUC.

Design and Setting  Retrospective review of medical records from 535 consecutive TTEs at an academic medical center was performed. The TTEs were classified according to 2011 AUC by 2 cardiologists blinded to clinical impact and were assessed for clinical impact by 2 cardiologists blinded to AUC. Clinical impact was assigned to 1 of the following 3 categories: (1) active change in care, (2) continuation of current care, or (3) no change in care.

Participants  Five hundred thirty-five patients undergoing TTE.

Exposure  Transthoracic echocardiography.

Main Outcomes and Measures  Prevalence of appropriate, inappropriate, and uncertain TTEs and prevalence of clinical impact subcategories.

Results  Overall, 31.8% of TTEs resulted in an active change in care; 46.9%, continuation of current care; and 21.3%, no change in care. By 2011 AUC, 91.8% of TTEs were appropriate; 4.3%, inappropriate; and 3.9%, uncertain. We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%; P = .29).

Conclusions and Relevance  Although 9 in 10 TTEs were appropriate by 2011 AUC, fewer than 1 in 3 TTEs resulted in an active change in care, nearly half resulted in continuation of current care, and slightly more than 1 in 5 resulted in no change in care. The low rate of active change in care (31.8%) among TTEs mostly classified as appropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care.

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Figure 1.
Study Design

AUC indicates appropriate use criteria; LVAD, left ventricular assist device; and TTE, transthoracic echocardiogram.

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Figure 2.
Appropriate Use Criteria Classification and Clinical Impact

Clinical impact for all, inappropriate, and appropriate transthoracic echocardiograms (TTEs).

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Figure 3.
Comparison of Growth in Transthoracic Echocardiography (TTE) Volume Between Medicare and the Veterans Affairs (VA) Healthcare System

Data were obtained from comparable periods from the studies by Andrus and Welch1 and Okrah et al.14

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