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.
Text Size: A A A
Published online

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.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours


Place holder to copy figure label and caption
Figure 1.
Study Design

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

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Appropriate Use Criteria Classification and Clinical Impact

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

Graphic Jump Location
Place holder to copy figure label and caption
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

Graphic Jump Location




Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Multimedia Related by Topic
Articles Related By Topic
Related Topics
PubMed Articles