|| Checking for direct PDF access through Ovid
Background: The American Heart Association has devised 202 appropriateness of use criteria (AUC) for echocardiography. They provide guidance for clinical decision-making and a potential framework for reimbursment. The impact of applying these criteria on current practice has not been assessed outside the USA.Setting. Tertiary regional cardiac centre serving a population of 1 million and performing 8,000 TTEs per year in South-West Wales, UK.Methods: We selected a random sample of transthoracic echocardiograms over a period of 6 months and analysed the requests forms, the clinical notes and the transthoracic echocardiography (TTE) reports in order to determine whether the requests were appropriate. We ascertained whether the result of the TTE was documented in the clinical notes, and whether it had prompted any change in the management of the patients' condition.Results: We selected 70 scans and excluded 2 (N=68) because we could not trace the clinical notes. There were 43 M; mean age (SD) was 66.2 (15.6) years, range 25-89 years. Forty-seven requests (69%) were appropriate, and 21 (31%) were not. By specialty there were 19/25 (76%) appropriate scans requested by tertiary cardiologists, 7/20 (35%) by cardiothoracic surgeons, 10/11 (91%) by secondary cardiologists, 9/9 (100%) by primary care physicians through the open-access service, and 1/3 (67%) by other specialties (p<0.0001 for cardiac surgeons vs. other specialties). New or unexpected findings leading to a change in management were present in 12 cases (18%): 2/21 (10%) of the inappropriate requests and 10/47 (21%) of the appropriate requests (p=NS). The most frequent appropriate indications (numbers denote the criterion number in the AHA guidelines, and square brackets denote the level of appropriateness, with the highest lvel =9) were: ‘70. Initial assessment of suspected heart failure’ [A9] – 11 requests (16%), ‘1. Symptoms potentially due to cardiac aetiology’ [A9] – 8 requests (12%), and the most frequent inappropriate indications were ‘48. Routine (<3 years after valve implantation) surveillance of prosthetic valve if no known or suspected valve dysfunction’ [I 3] - 9 requests (13%) and ‘43. Routine (<3 years) surveillance of mild valvular regurgitation w/o change in clinical status or cardiac exam’ [I2] – 5 requests (7%). Scan results were documented in the notes in 59 (87%) of cases.Conclusions: Major potential reductions in the number of transthoracic echocardiograms could be achieved by adhering to appropriateness criteria, mainly by rejecting inappropriate requests from cardiothoracic surgeons and tertiary cardiologists.