European Heart Journal – Cardiovascular Imaging (2014) 15, 450–455 doi:10.1093/ehjci/jet186
Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? Maria-Magdalena Gurzun * and Adrian Ionescu Department of Cardiology, Regional Cardiac Centre Morriston, Morriston Hospital, Swansea, UK Received 23 July 2013; accepted after revision 23 September 2013; online publish-ahead-of-print 22 October 2013
Appropriateness of use criteria (AUC) for transthoracic echocardiography (TTE) have been developed by American cardiology associations to help avoid unnecessary scans by formalizing indications for imaging. There are 98 indications classified as either appropriate (A), inappropriate (I), or uncertain (U). AUC may allow better targeting of limited resources, but they have not been tested systematically outside the USA. ..................................................................................................................................................................................... Aim of the study To test AUC in Wales, one of the four countries of the UK. ..................................................................................................................................................................................... Methods We collected requests for TTE and the corresponding TTE reports from all Welsh hospitals during 1 week in June 2012 and analysed them according to appropriateness, specialty, and location (secondary vs. tertiary services) of the referring physician. ..................................................................................................................................................................................... Results We analysed 1070 pairs of echocardiography requests and TTE reports from 14 hospitals [mean age 66.5 (16.1) years; 579 (51%) M]: A—922 (86%); I—115 (11%), and U—33 (3%); 287 (25%) studies were from two tertiary centres and 338 (29.5%) were of inpatients. Main indications were the evaluation of: cardiac structure and function (489, 45.7%), valvular function (267, 25%), and hypertension, heart failure, or cardiomyopathy (149, 13.9%). In-patient requests (main indication—‘initial evaluation of left ventricle ejection fraction post acute coronary syndrome’—44 studies, 13.7%) were more often appropriate than outpatients (main indication—‘symptoms/conditions potentially related to suspected cardiac aetiology’—142 studies, 19.8%): 94.4 vs. 83.5%, P , 0.05. The most common inappropriate indication was ‘initial evaluation for a murmur/click without symptoms/signs of structural heart disease’ (29 studies, 2.7%). The proportion of appropriate requests by specialty was 89% for medical, 87% for GPs, 85.3% for cardiologists, 80.8% for surgical, and 60% for cardiac surgeons (P , 0.05 for cardiac surgeons); 47.8% of requests were generated by cardiologists, and abnormalities were detected in 82% of all scans (37% minor findings and 45% major findings), least often in those requested by general practitioners. ..................................................................................................................................................................................... Conclusion Application of AUC yields results similar to those reported from the USA; 1 in 10 scans could be avoided.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Appropriateness of use criteria † Echocardiography
Introduction Appropriateness of use criteria (AUC) for echocardiography (ECHO) were developed by the American Society of Echocardiography, the American College of Cardiology, and a number of other American professional organizations in 2007 and have been revised in 2011.1,2 They are recommendations ‘regarding the appropriateness of transthoracic (TTE), transoesophageal, and stress
echocardiography in an expanded number of clinical scenarios’.2 The primary reason for their advent is concern that un-necessary requests for imaging tests in general and ECHO in particular are wasteful and relatively common. Very few studies have assessed how clinical requests for ECHO compare with the AUC,3 – 9 and most are single-centre efforts from academic institutions in the USA. Concerns about inappropriate use of ECHO are raised periodically in the UK, and anecdotal reports, as well as a small single-centre
* Corresponding author. Tel: +44 400740239647; E-mail: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: [email protected]
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Background
451
Appropriateness of use criteria for TTE
audit,10 suggest that inappropriate echo requests do occur, but formal data about this topic are not available. We collected data from all hospitals that perform adult TTE in Wales, one of the four countries of the UK, and analysed whether the indications for TTE comply with the AUC, and what factors correlate with deviations from the AUC. We wanted to determine whether screening requests for TTE by applying AUC might reduce activity levels and help release some of the pressure on ECHO departments in an UK context.
Methods Appropriateness of use criteria
Data collection and analysis A population of Wales has 3.06 million11 and cardiac health care (including ECHO) is provided by the Welsh National Health Service (NHS). We used the All-Wales Cardiac Network to identify hospitals in Wales that perform ECHO, and sent a questionnaire to the technical head of ECHO in each institution to document administrative structures, activity, staffing and equipment levels, and to invite them to participate in this study. Centres were then asked to collect all TTE requests received as well as the corresponding reports generated during a single week in June 2012 and to forward them, in an anonymized format, to the authors. The clinical indication for TTE was determined by performing a detailed review of pre-procedural clinical documentation (clinical presentation, medical history, and reason for scan requesting) as documented in the request form. These clinical indications were then summarized and matched (when possible) with a single main indication for TTE from the list of 98 indications described in the 2011 AUC document.2 All studies were performed and interpreted according to the British Society of Echocardiography recommendations. Studies were classified as: normal, studies with minor TTE abnormalities, or studies with significant TTE abnormalities. A ‘significant TTE abnormality’ was defined as: at least moderate left ventricular systolic dysfunction (left ventricle ejection fraction ,40% or LV function described as moderately impaired in the report), presence of regional wall motion abnormality involving at least two LV segments), grade II or III diastolic dysfunction or elevated left ventricle filling pressure, at least moderate valvular regurgitation, aortic stenosis with aortic valve area of ,1.5 cm2, mitral stenosis with mitral valve area of ,1.5 cm2, estimated pulmonary artery systolic pressure of .50 mmHg, moderate or severe pericardial effusion, intracardiac mass/thrombus/vegetation, left ventricular outflow tract obstruction, and findings suggestive of apical hypertrophy.2
Statistical analysis Means and standard deviations (SDs) were calculated for continuous variables. Comparisons were performed using the x 2 test for categorical data, and Student’s t-test for continuous data with a two-tailed P-value of ,0.05 for statistical significance (IBM SPSS Statistics v.21, Armonk, NY, USA).
We received 1148 pairs of echocardiographic referrals and reports from 14 hospitals. The mean age (SD) of patients studied was 66.5 (16.1) years; 579 (51%) were males. Two hundred and eighty-seven (25%) studies were performed in the two tertiary centres in Wales and 338 (29.5%) were of inpatients. The total number of TTE studies in Wales was estimated at 90 000 scans annually, mean 4600 scans/hospital, SD 2200. Three percentage of request forms did not provide enough data for classification and 3.8% of the remaining studies were unclassifiable according to 2011 AUC; both these categories were excluded from further analysis. Of the remaining 1070 studies, 922 (86%) were appropriate (A), 115 (11%) inappropriate (I), and 33 (3%) uncertain (U). Indications for TTE were distributed as follows: almost half 489 (45.7%) were requested for the general evaluation of cardiac structure and function, 266 (25%) for valvular function, 149 (13.9%) for hypertension, heart failure, or cardiomyopathy, 83 (7.8%) for intraand extracardiac structures or chambers, 75 (7%) for cardiovascular evaluation in acute settings, 7 (0.6%) for aortic disease, and 1 (0.1%) for adult congenital heart disease. Overall, the most frequent ‘appropriate’ indication for ECHO (Table 1) was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1 in the AUC document2). Of 191 (17.9%) patients who were scanned for this indication, the main symptom was shortness of breath in 91 (47.6%), chest pain in 30 (15.7%), palpitations in 5 (2.6%), other symptoms in 27 (14.1%), and a combination of two or more symptoms in 38 (19.9%) patients.
Out- vs. in-patients settings The proportion of appropriate studies was higher among inpatients compared with outpatients (94.4 vs. 83.5%, P , 0.05) (Table 2). The most common appropriate indication for ECHO in outpatients (142 studies, 19.8% of all outpatient studies) was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1 in the AUC document2), whereas for inpatients (43 studies, 13.7% of all inpatient studies) it was ‘initial evaluation of ventricular function following acute coronary syndrome’ (Indication 24). The most common ‘inappropriate’ indication for ECHO for outpatients and inpatients was Indication 35 (‘initial evaluation for a murmur or click when there are no other symptoms or signs of valvular or structural heart disease’) in 29 studies (2.7% from all patients) (Table 1). Frequent inappropriate indications for outpatients were also Indications 11 (‘routine surveillance of ventricular function with known coronary artery disease (CAD) and no change in clinical status or cardiac exam’) or 38 (‘routine surveillance (,3 year) of mild valvular stenosis without a change in clinical status or cardiac exam’) (13% and, respectively, 12% from all outpatients’ inappropriate studies). The main inappropriate indications for in-patients were Indications 28 (‘suspected pulmonary embolism in order to establish diagnosis’) and 60 (‘routine surveillance of known small pericardial effusion with no change in clinical status’), while Indication 14 (‘routine perioperative evaluation of cardiac structure and function prior to non-cardiac solid organ transplantation’) was the main uncertain indication encountered.
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AUC for TTE were published first in 2007 and have been updated in 2011. We used the 2011 version.2 Briefly, the AUC document lists 98 indications for TTE, and each is graded from 1 to 9, with lowest scores (1–3) denoting inappropriate indications, medium scores (4–6) identifying uncertain indications, and high scores (7–9) designating appropriate indications.
Results
452
Table 1
G. Maria-Magdalena and A. Ionescu
Main appropriate and inappropriate indications for TTE in the study population
Appropriate indications Symptoms or conditions potentially related to suspected cardiac aetiology including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event (1) Sustained or non-sustained atrial fibrillation, SVT, or VT (5)
16.6% 7.8%
Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease (34)
7.2%
Suspected cardiovascular source of embolus (58) Prior testing that concerning for heart disease or structural abnormality including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers (2) Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms, signs, or abnormal test results (70)
4.8% 4.6%
Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/syncope (including but not limited to aortic stenosis, hypertrophic cardiomyopathy, or HF) (7) Inappropriate indications
3.7%
Initial evaluation when there are no other symptoms or signs of valvular or structural heart disease (35)
2.7%
Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam (11) Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease (12)
1.3% 1.1%
3.7%
Appropriateness of TTE and specialty of requesting physician
implantation of prosthetic valve if no known or suspected valve dysfunction’ (Indication 48, 20% of studies, P , 0.05).
Cardiologists requested 512 (47.8%) of the scans. Other medical specialties (general internal medicine, care of the elderly, respiratory medicine, and anaesthetics) requested 348 (32.5%), general practitioners (GPs) 70 (6.5%), surgical specialities 52 (4.9%), and cardiothoracic surgeons 30 (2.8%) studies. The proportions of appropriate requests were 89% for medical specialties, 87% for general practitioners, 85.3% for cardiologists, 80.8% for surgical specialties, and 60% for cardiac surgeons (P , 0.05 for cardiac surgeons vs. other specialties). For all specialties combined, the main appropriate indication for ECHO was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1) (15.9% of cardiologists’ referrals, 16% of other medical specialities’, 19.2% of other surgical specialities’, and 39.2% of general practitioners’ referrals), except for cardiac surgeons. For studies requested by cardiac surgeons, the most frequent appropriate indication was ‘initial postoperative evaluation of prosthetic valve for the establishment of baseline’ (Indication 47) in 4 (16%) patients. Approximately 6% of all analysed studies were for preoperative assessment for non-cardiac surgery and 14 (22%) of these were inappropriate. The proportion and the type of inappropriate TTE requests varied widely among specialties. For cardiologists, the most common inappropriate indication was routine ‘surveillance of ventricular function with known coronary artery disease and no change in clinical status or cardiac exam’ (Indication 11) (2% of studies); for other medical specialities (1.9% of studies) and general practitioners (8.1% of studies), it was ‘initial evaluation of a murmur or click when there are no other signs of valvular or structural heart disease’ (Indication 35); for surgical specialities—‘routine preoperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease’ (Indication 13) (5.8% of studies) and for cardiac surgeons—‘routine surveillance of ,3 years after valve
Echocardiographic findings according to the appropriateness of indication Eighteen percentage of all studies were classified as normal, 37% as showing ‘minor TTE findings’ and 45% as showing ‘major TTE findings’. Half of cardiologist-generated referrals yielded major TTE findings compared with a third of GP referrals (P , 0.05). Only a sixth of cardiology referrals yielded normal studies compared with a third of GP referrals (P , 0.05). More than half of the GP requests for Indication 1 (‘symptoms or conditions potentially related to suspected cardiac aetiology’) yielded normal studies, compared with an overall 27% prevalence of normal studies among those requested for this indication (P , 0.05). Inappropriate requests, and requests in outpatient settings, yielded a higher proportion of normal studies than appropriate requests, with no difference between tertiary and secondary centres (Table 3). A minority (3.8%) of analysed studies could not be classified. Indications in this group included: postoperative assessment or follow-up for mitral valve repair, post-procedural assessment or follow up after device implantation, assessment of LV systolic function before and after cardiac surgery, pre- and post-direct current cardioversion, pre transcatheter aortic valve implanation assessment, familial history of sudden cardiac death, and cardiac screening in systemic disease.
Discussion In an observational study encompassing all echocardiograms performed throughout a week in all hospitals in Wales, we found that the majority of clinical requests for TTE were formulated by cardiologists and were classifiable and appropriate according to the 2011 AUC document from the AHA/ASE/ACC. We found significant
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Figures in brackets denote the number assigned to the respective indication in the AUC document (Douglas et al. 2). For Indication 2, the most frequent prior test that suggested heart disease was the chest X ray—39.6% of cases (35.8% for cardiomegaly and 3.8% for congestion), followed by ECG changes (27.5%). TIA, transient ischaemic attack; SVT, supraventricular tachycardia; VT, ventricular tachycardia; HF, heart failure; CAD, coronary artery disease.
453
Appropriateness of use criteria for TTE
Table 2
Study classification according to AUC (2011 version) in different clinical settings Appropriate (%)
Uncertain (%)
Inappropriate (%)
P-value
84 87.7
3.6 2.6
11.3 9.7
0.34
94.4 83.1
1.6 3.8
4 13.1
,0.05
Cardiology Cardiothoracic surgery
85.3 60
4.8 0
9.9 40
,0.05
Other medical specialities
89
2.2
8.8
Other surgical specialities GP
80.8 87
0 1.4
19.2 10.8
............................................................................................................................................................................... Tertiary vs. DGH Tertiary Non-tertiary In- vs. out-patients In-patients Out-patients Referring specialty
Table 3
Comparison of echocardiographic findings in different settings Normal (%)
Minor TTE findings (%)
Major TTE findings (%)
P-value
16.1
33.7
50
,0.005
44
40
............................................................................................................................................................................... Speciality of referral consultant Cardiology Cardiothoracic surgery
8
Other medical specialities Other surgical specialities
17.6 21.2
40.2 46.2
41.6 32.7
GP
29.7
36.5
33.8
26.1
41.7
30.4
18.2
21.2
60.6
17.0
37.0
45.7
Appropriate vs. inappropriate studies Inappropriate Uncertain Appropriate Tertiary vs. DGH Tertiary centres
19.5
38.5
41.4
DGH In- vs. out-patients
17.6
36.7
45.4
In-patients Out-patients
9.6
31.7
58.4
21.3
39.9
38.2
differences between specialities in terms of appropriateness of ECHO and showed that outpatient scans were more often inappropriate than scans requested for in-patients, with ‘a routine ECHO follow-up’ in stable patients accounting for most of the inappropriate requests, that appropriate scans, and those requested by cardiologists, yield abnormalities more often than inappropriate scans, and that scans requested by GPs have a high proportion of normal studies. To our knowledge, this is the first study to apply the 2011 AUC criteria to an UK patient population, and only the second to have looked at AUC utilization in Europe In the USA, compliance with AUC is essential: requests for imaging tests are authorized by private health insurance plans only if they comply with ‘radiology benefits manager pre-certification criteria,’
0.004
0.58
,0.005
which are in line with AUC. In the UK NHS and in most European countries, the financial pressures on imaging are also intense, but the link between appropriateness and cost is rarely ‘felt’ by the physicians who order the test, which perhaps helps explain the relative lack of interest for AUC in the European echocardiography community. We think that this is likely to change, as cost-consciousness increases among health-care professionals.
What do we know from previous studies? The first wave of studies assessing the performance of the AUC appeared in the wake of the publication of the first version in 2007.13 – 15 These studies were performed mainly in academic centres and demonstrated that a significant minority of indications
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Numbers are percentages. GP, general practitioner; DGH, district general hospital.
454
Table 4
G. Maria-Magdalena and A. Ionescu
Summary of previous studies that have assessed the clinical application of AUC
Author and year of publication
Number of patients
Setting
AUC version
Comments
Appropriateness of requests for echocardiography (%)
..................................
NC
A
U
I
2011
2
82
7
11
............................................................................................................................................................................... Mansour et al.6
2247 (1553 TTE)
Acad.
Abnormal findings more common in A than in I studies
2007
11
89
0
11
Acad., comm.
2011
2
71
7
22
2007
23
83
0
17
1179
Regnl.
2011
96.5
0.4
2.4
86
0
1
Alqarqaz et al.9
170
Acad.
77
14
9
77
0
9
Parikh et al.7
384
Acad.
92.2
0.5
1.8
86.7
0
0.8
Ballo et al.4
931
Comm., in-pt
2011
1.2
80.3
5
14.7
A and U indications impacted clinical care more often than I ones
Patil et al.8
1820
Acad.
2011
0.4
82
5.3
12.3
Routine surveillance without change in clinical status was the most common I indication
Bhatia et al.5
450
Bailey et al.3
2007
13
2011 14
2011 2007
5.5 12,5
93% of the undefined studies (2007) could be classified using 2011 AUC A studies more likely to show new/major findings resulting in patient care or intervention Revised criteria successful in addressing an increased number of clinical indications
A, appropriate; NC, not classifiable; U, uncertain; I, inappropriate; Acad, academic hospital; Regnl, regional hospital; Comm, community hospital; in-pt, in-patients; OPD, outpatients department.
(between 12 –35%) were not captured by the criteria and were deemed ‘unclassifiable’. Of the remaining studies, around 55–85% were deemed appropriate. It was not clear whether appropriately requested scans were more likely to identify relevant abnormalities than inappropriate ones, as results were divergent between studies. This early experience spurred a process of refining the AUC which produced the revised criteria in 2011. The published experience with these is summarized in Table 4. The revised AUC have virtually eliminated the ‘unclassified’ category of indications (it now represents only around 2% of requests). However, although the proportion of inappropriate scans has increased slightly, to the detriment of appropriate scans, all studies using the revised AUC have found that appropriate indications are more often associated with new, unexpected, or actionable findings than inappropriate ones. Outpatient settings seem more prone to inappropriate indications, and cardiologists ‘get it right’ more often than other specialties, while ‘routine’ ECHO monitoring in the absence of a change in clinical status is the main cause of inappropriate scans.
What does this study show? This is the first study to assess AUC in a large geographical area with a unified and homogenous health-care system (Wales, UK), in the District General Hospitals of various sizes, as well as in two tertiary centres. The proportions of appropriate (86%), inappropriate (11%), and uncertain indications (3%) were similar to the findings of previous studies. The only European study that has applied AUC4 reported that virtually all (98.8%) indications for TTE in 931 patients in five community hospitals were captured by the revised
criteria. Indications were appropriate in 80.3%, inappropriate in 14.7%, and of uncertain appropriateness in 5% of cases. Interestingly, after analysing an independent sample of 259 patients who had been discharged from the hospital during the same period, the authors report that 16.2% fulfilled criteria for being offered a TTE, without one having been requested. The most common inappropriate indication for ECHO for outpatients and inpatients was Indication 35 (‘initial evaluation for a murmur or click when there are no other symptoms or signs of valvular or structural heart disease’) in 29 studies (2.7% from all patients). However, the definition ‘35’ is of dubious clinical relevance. When there is an auscultation evidence for a ‘click’ or murmur from the clinical examination, it is difficult to justify deferral of an echocardiographic study. We found that the highest proportion of inappropriate indications came from cardiac surgeons, who request TTE ‘routinely’ in patients with prosthetic heart valves whenever they are seen in the outpatient department, with little correlation with the clinical status. We confirmed the finding from previous studies that requests for outpatient TTE are more frequently inappropriate than in-patient requests. Inappropriate studies were more often normal than appropriate ones. Indication 1 (‘symptoms related to suspect cardiac aetiology’) was the most frequent reason for requesting an ECHO in outpatients, but its ‘yield’ depends on the clinical skills of the physician referring the patient. Of all patients referred for Indication 1, almost a third had normal scans; half of those referred for this indication by GPs were also normal. This suggests that better targeting of ECHO by
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2007
I: 30% in academic OPD, 21% in community OPD, 14% in academic in-patient setting
Appropriateness of use criteria for TTE
GPs might increase the yield of TTE and reduce the proportion of unnecessary scans.
Limitations The AUC have been developed in the USA, and this is an UK study. However, the methodology of the AUC has been carefully developed, and the revised criteria have been validated extensively, suggesting that their use can be justified outside the USA. The fact that our results are very similar to those reported from the USA and to those of the only European study, to date, also supports the use of AUC in the UK context. Our data collection was based on questionnaires filled in by the participating centres. We did not have access to the full clinical sets of notes for the patients included in this study, so we could not document the ‘downstream’ impact on the echocardiographic findings.
The proportion of appropriate, inappropriate, uncertain, and unclassifiable studies according to the 2011 AUC is similar in Wales, UK, to that reported from the USA and from the only other European study. This suggests that applying the AUC for screening ECHO requests in the UK setting might be feasible. A strict application of AUC has the potential to reduce the total ECHO workload in Wales by 9000 scans/year. Moreover, increasing the proportion of requests for ECHO that originates with cardiologists rather than with primary care physicians can increase the ‘yield’ and effectiveness of ECHO. The net effect of a strict application of AUC on the costs of health care requires a further study. Conflict of interest: This work was supported by a Romanian Society of Cardiology Research Grant.
References 1. Martin ET, Messer JV, Miller AB, Picard MH, Raggi P, Reed KD et al. ACCF/ASE/ACEP/ ASNC/SCAI/SCCT/SCMR 2007 Appropriateness criteria for transthoracic and transesophageal echocardiography. J Am Coll Cardiol 2007;50:187 – 204.
2. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR et al. ACCF/ASE/ AHA/ASNC /HFSA/HRS/SCAI /SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography. J Am Soc Echocardiogr 2011;24:229 –67. 3. Bailey S, Mosteanu I, Tietjen P, Petrini J, Alexander J, Keller A. The use of transthoracic echocardiography and adherence to appropriate use criteria at a regional hospital. J Am Soc Echocardiogr 2012;25:1015 –22. 4. Ballo P, Bandini F, Capecchi I, Chiodi L, Ferro G, Fortini A et al. Application of 2011 ACC/ASE appropriateness of use criteria in hospitalized patients referred for transthoracic echocardiography in a community setting. J Am Soc Echocardiogr 2012;25: 589 –98. 5. Bhatia S, Carne D, Picard M, Weiner R. Comparison of the 2007 and 2011 appropriate use criteria for transthoracic echocardiography in various clinical settings. J Am Soc Echocardiogr 2012;25:1162 –9. 6. Mansour I, Razi R, Bhave N, Ward P. Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal and stress echocardiography. J Am Soc Echocardiogr 2012;25:1153 –61. 7. Parikh P, Asheld J, Kort S. Does the revised appropriate use criteria for echocardiography represent an improvement over the initial criteria? A comparison between the 2011 and the 2007 appropriateness of use criteria for echocardiography. J Am Soc Echocardiogr 2012;25:228–33. 8. Patil H, Coggins T, Kusnetzky L, Main M. Evaluation of appropriate use of transthoracic echocardiography in 1820 consecutive patients using the 2011 revised appropriate use criteria for echocardiography. Am J Cardiol 2012;109:1814 –7. 9. Alqarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriateness of use criteria for transthoracic and transesophageal echocardiography. Int J Cardiovasc Imaging 2012;28:1951 – 8. 10. Vijayan S, Khanji M, Ionescu A. Can application of appropriateness of use criteria reduce the workload in a tertiary echocardiographic laboratory? A single centre experience. Eur J Echocardiogr 2011;12(Abstract supplement):i44. 11. Office of National Statistics. http://www.ons.gov.uk (1 March 2013). 12. Kirkpatrick JN, Ky B, Rahmouni HW, Chirinos JA, Farmer SA, Fields AV et al. Application of appropriateness criteria in outpatient transthoracic echocardiography. J Am Soc Echocardiogr 2009;22:53–9. 13. Martin NM, Picard MH. Use and appropriateness of transthoracic echocardiography in an academic medical center: a pilot observational study. J Am Soc Echocardiogr 2009; 22:48 –52. 14. Willens HJ, Go´mez-Marı´n O, Heldman A, Chakko S, Postel C, Hasan T et al. Adherence to appropriateness criteria for transthoracic echocardiography: comparisons between a regional department of Veterans Affairs health care system and academic practice and between physicians and mid-level providers. J Am Soc Echocardiogr 2009; 22:793–9. 15. Ward RP, Krauss D, Mansour IN, Lemieux N, Gera N, Lang RM. American College of Cardiology Foundation/American Society of Echocardiography Comparison of the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria for outpatient transthoracic echocardiography in academic and community practice settings. J Am Soc Echocardiogr 2009;22:1375 –81.
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Conclusions
455
Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? Maria-Magdalena Gurzun * and Adrian Ionescu Department of Cardiology, Regional Cardiac Centre Morriston, Morriston Hospital, Swansea, UK Received 23 July 2013; accepted after revision 23 September 2013; online publish-ahead-of-print 22 October 2013
Appropriateness of use criteria (AUC) for transthoracic echocardiography (TTE) have been developed by American cardiology associations to help avoid unnecessary scans by formalizing indications for imaging. There are 98 indications classified as either appropriate (A), inappropriate (I), or uncertain (U). AUC may allow better targeting of limited resources, but they have not been tested systematically outside the USA. ..................................................................................................................................................................................... Aim of the study To test AUC in Wales, one of the four countries of the UK. ..................................................................................................................................................................................... Methods We collected requests for TTE and the corresponding TTE reports from all Welsh hospitals during 1 week in June 2012 and analysed them according to appropriateness, specialty, and location (secondary vs. tertiary services) of the referring physician. ..................................................................................................................................................................................... Results We analysed 1070 pairs of echocardiography requests and TTE reports from 14 hospitals [mean age 66.5 (16.1) years; 579 (51%) M]: A—922 (86%); I—115 (11%), and U—33 (3%); 287 (25%) studies were from two tertiary centres and 338 (29.5%) were of inpatients. Main indications were the evaluation of: cardiac structure and function (489, 45.7%), valvular function (267, 25%), and hypertension, heart failure, or cardiomyopathy (149, 13.9%). In-patient requests (main indication—‘initial evaluation of left ventricle ejection fraction post acute coronary syndrome’—44 studies, 13.7%) were more often appropriate than outpatients (main indication—‘symptoms/conditions potentially related to suspected cardiac aetiology’—142 studies, 19.8%): 94.4 vs. 83.5%, P , 0.05. The most common inappropriate indication was ‘initial evaluation for a murmur/click without symptoms/signs of structural heart disease’ (29 studies, 2.7%). The proportion of appropriate requests by specialty was 89% for medical, 87% for GPs, 85.3% for cardiologists, 80.8% for surgical, and 60% for cardiac surgeons (P , 0.05 for cardiac surgeons); 47.8% of requests were generated by cardiologists, and abnormalities were detected in 82% of all scans (37% minor findings and 45% major findings), least often in those requested by general practitioners. ..................................................................................................................................................................................... Conclusion Application of AUC yields results similar to those reported from the USA; 1 in 10 scans could be avoided.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Appropriateness of use criteria † Echocardiography
Introduction Appropriateness of use criteria (AUC) for echocardiography (ECHO) were developed by the American Society of Echocardiography, the American College of Cardiology, and a number of other American professional organizations in 2007 and have been revised in 2011.1,2 They are recommendations ‘regarding the appropriateness of transthoracic (TTE), transoesophageal, and stress
echocardiography in an expanded number of clinical scenarios’.2 The primary reason for their advent is concern that un-necessary requests for imaging tests in general and ECHO in particular are wasteful and relatively common. Very few studies have assessed how clinical requests for ECHO compare with the AUC,3 – 9 and most are single-centre efforts from academic institutions in the USA. Concerns about inappropriate use of ECHO are raised periodically in the UK, and anecdotal reports, as well as a small single-centre
* Corresponding author. Tel: +44 400740239647; E-mail: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: [email protected]
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Background
451
Appropriateness of use criteria for TTE
audit,10 suggest that inappropriate echo requests do occur, but formal data about this topic are not available. We collected data from all hospitals that perform adult TTE in Wales, one of the four countries of the UK, and analysed whether the indications for TTE comply with the AUC, and what factors correlate with deviations from the AUC. We wanted to determine whether screening requests for TTE by applying AUC might reduce activity levels and help release some of the pressure on ECHO departments in an UK context.
Methods Appropriateness of use criteria
Data collection and analysis A population of Wales has 3.06 million11 and cardiac health care (including ECHO) is provided by the Welsh National Health Service (NHS). We used the All-Wales Cardiac Network to identify hospitals in Wales that perform ECHO, and sent a questionnaire to the technical head of ECHO in each institution to document administrative structures, activity, staffing and equipment levels, and to invite them to participate in this study. Centres were then asked to collect all TTE requests received as well as the corresponding reports generated during a single week in June 2012 and to forward them, in an anonymized format, to the authors. The clinical indication for TTE was determined by performing a detailed review of pre-procedural clinical documentation (clinical presentation, medical history, and reason for scan requesting) as documented in the request form. These clinical indications were then summarized and matched (when possible) with a single main indication for TTE from the list of 98 indications described in the 2011 AUC document.2 All studies were performed and interpreted according to the British Society of Echocardiography recommendations. Studies were classified as: normal, studies with minor TTE abnormalities, or studies with significant TTE abnormalities. A ‘significant TTE abnormality’ was defined as: at least moderate left ventricular systolic dysfunction (left ventricle ejection fraction ,40% or LV function described as moderately impaired in the report), presence of regional wall motion abnormality involving at least two LV segments), grade II or III diastolic dysfunction or elevated left ventricle filling pressure, at least moderate valvular regurgitation, aortic stenosis with aortic valve area of ,1.5 cm2, mitral stenosis with mitral valve area of ,1.5 cm2, estimated pulmonary artery systolic pressure of .50 mmHg, moderate or severe pericardial effusion, intracardiac mass/thrombus/vegetation, left ventricular outflow tract obstruction, and findings suggestive of apical hypertrophy.2
Statistical analysis Means and standard deviations (SDs) were calculated for continuous variables. Comparisons were performed using the x 2 test for categorical data, and Student’s t-test for continuous data with a two-tailed P-value of ,0.05 for statistical significance (IBM SPSS Statistics v.21, Armonk, NY, USA).
We received 1148 pairs of echocardiographic referrals and reports from 14 hospitals. The mean age (SD) of patients studied was 66.5 (16.1) years; 579 (51%) were males. Two hundred and eighty-seven (25%) studies were performed in the two tertiary centres in Wales and 338 (29.5%) were of inpatients. The total number of TTE studies in Wales was estimated at 90 000 scans annually, mean 4600 scans/hospital, SD 2200. Three percentage of request forms did not provide enough data for classification and 3.8% of the remaining studies were unclassifiable according to 2011 AUC; both these categories were excluded from further analysis. Of the remaining 1070 studies, 922 (86%) were appropriate (A), 115 (11%) inappropriate (I), and 33 (3%) uncertain (U). Indications for TTE were distributed as follows: almost half 489 (45.7%) were requested for the general evaluation of cardiac structure and function, 266 (25%) for valvular function, 149 (13.9%) for hypertension, heart failure, or cardiomyopathy, 83 (7.8%) for intraand extracardiac structures or chambers, 75 (7%) for cardiovascular evaluation in acute settings, 7 (0.6%) for aortic disease, and 1 (0.1%) for adult congenital heart disease. Overall, the most frequent ‘appropriate’ indication for ECHO (Table 1) was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1 in the AUC document2). Of 191 (17.9%) patients who were scanned for this indication, the main symptom was shortness of breath in 91 (47.6%), chest pain in 30 (15.7%), palpitations in 5 (2.6%), other symptoms in 27 (14.1%), and a combination of two or more symptoms in 38 (19.9%) patients.
Out- vs. in-patients settings The proportion of appropriate studies was higher among inpatients compared with outpatients (94.4 vs. 83.5%, P , 0.05) (Table 2). The most common appropriate indication for ECHO in outpatients (142 studies, 19.8% of all outpatient studies) was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1 in the AUC document2), whereas for inpatients (43 studies, 13.7% of all inpatient studies) it was ‘initial evaluation of ventricular function following acute coronary syndrome’ (Indication 24). The most common ‘inappropriate’ indication for ECHO for outpatients and inpatients was Indication 35 (‘initial evaluation for a murmur or click when there are no other symptoms or signs of valvular or structural heart disease’) in 29 studies (2.7% from all patients) (Table 1). Frequent inappropriate indications for outpatients were also Indications 11 (‘routine surveillance of ventricular function with known coronary artery disease (CAD) and no change in clinical status or cardiac exam’) or 38 (‘routine surveillance (,3 year) of mild valvular stenosis without a change in clinical status or cardiac exam’) (13% and, respectively, 12% from all outpatients’ inappropriate studies). The main inappropriate indications for in-patients were Indications 28 (‘suspected pulmonary embolism in order to establish diagnosis’) and 60 (‘routine surveillance of known small pericardial effusion with no change in clinical status’), while Indication 14 (‘routine perioperative evaluation of cardiac structure and function prior to non-cardiac solid organ transplantation’) was the main uncertain indication encountered.
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AUC for TTE were published first in 2007 and have been updated in 2011. We used the 2011 version.2 Briefly, the AUC document lists 98 indications for TTE, and each is graded from 1 to 9, with lowest scores (1–3) denoting inappropriate indications, medium scores (4–6) identifying uncertain indications, and high scores (7–9) designating appropriate indications.
Results
452
Table 1
G. Maria-Magdalena and A. Ionescu
Main appropriate and inappropriate indications for TTE in the study population
Appropriate indications Symptoms or conditions potentially related to suspected cardiac aetiology including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event (1) Sustained or non-sustained atrial fibrillation, SVT, or VT (5)
16.6% 7.8%
Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease (34)
7.2%
Suspected cardiovascular source of embolus (58) Prior testing that concerning for heart disease or structural abnormality including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers (2) Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms, signs, or abnormal test results (70)
4.8% 4.6%
Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/syncope (including but not limited to aortic stenosis, hypertrophic cardiomyopathy, or HF) (7) Inappropriate indications
3.7%
Initial evaluation when there are no other symptoms or signs of valvular or structural heart disease (35)
2.7%
Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam (11) Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease (12)
1.3% 1.1%
3.7%
Appropriateness of TTE and specialty of requesting physician
implantation of prosthetic valve if no known or suspected valve dysfunction’ (Indication 48, 20% of studies, P , 0.05).
Cardiologists requested 512 (47.8%) of the scans. Other medical specialties (general internal medicine, care of the elderly, respiratory medicine, and anaesthetics) requested 348 (32.5%), general practitioners (GPs) 70 (6.5%), surgical specialities 52 (4.9%), and cardiothoracic surgeons 30 (2.8%) studies. The proportions of appropriate requests were 89% for medical specialties, 87% for general practitioners, 85.3% for cardiologists, 80.8% for surgical specialties, and 60% for cardiac surgeons (P , 0.05 for cardiac surgeons vs. other specialties). For all specialties combined, the main appropriate indication for ECHO was ‘symptoms or conditions potentially related to suspected cardiac aetiology’ (Indication 1) (15.9% of cardiologists’ referrals, 16% of other medical specialities’, 19.2% of other surgical specialities’, and 39.2% of general practitioners’ referrals), except for cardiac surgeons. For studies requested by cardiac surgeons, the most frequent appropriate indication was ‘initial postoperative evaluation of prosthetic valve for the establishment of baseline’ (Indication 47) in 4 (16%) patients. Approximately 6% of all analysed studies were for preoperative assessment for non-cardiac surgery and 14 (22%) of these were inappropriate. The proportion and the type of inappropriate TTE requests varied widely among specialties. For cardiologists, the most common inappropriate indication was routine ‘surveillance of ventricular function with known coronary artery disease and no change in clinical status or cardiac exam’ (Indication 11) (2% of studies); for other medical specialities (1.9% of studies) and general practitioners (8.1% of studies), it was ‘initial evaluation of a murmur or click when there are no other signs of valvular or structural heart disease’ (Indication 35); for surgical specialities—‘routine preoperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease’ (Indication 13) (5.8% of studies) and for cardiac surgeons—‘routine surveillance of ,3 years after valve
Echocardiographic findings according to the appropriateness of indication Eighteen percentage of all studies were classified as normal, 37% as showing ‘minor TTE findings’ and 45% as showing ‘major TTE findings’. Half of cardiologist-generated referrals yielded major TTE findings compared with a third of GP referrals (P , 0.05). Only a sixth of cardiology referrals yielded normal studies compared with a third of GP referrals (P , 0.05). More than half of the GP requests for Indication 1 (‘symptoms or conditions potentially related to suspected cardiac aetiology’) yielded normal studies, compared with an overall 27% prevalence of normal studies among those requested for this indication (P , 0.05). Inappropriate requests, and requests in outpatient settings, yielded a higher proportion of normal studies than appropriate requests, with no difference between tertiary and secondary centres (Table 3). A minority (3.8%) of analysed studies could not be classified. Indications in this group included: postoperative assessment or follow-up for mitral valve repair, post-procedural assessment or follow up after device implantation, assessment of LV systolic function before and after cardiac surgery, pre- and post-direct current cardioversion, pre transcatheter aortic valve implanation assessment, familial history of sudden cardiac death, and cardiac screening in systemic disease.
Discussion In an observational study encompassing all echocardiograms performed throughout a week in all hospitals in Wales, we found that the majority of clinical requests for TTE were formulated by cardiologists and were classifiable and appropriate according to the 2011 AUC document from the AHA/ASE/ACC. We found significant
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Figures in brackets denote the number assigned to the respective indication in the AUC document (Douglas et al. 2). For Indication 2, the most frequent prior test that suggested heart disease was the chest X ray—39.6% of cases (35.8% for cardiomegaly and 3.8% for congestion), followed by ECG changes (27.5%). TIA, transient ischaemic attack; SVT, supraventricular tachycardia; VT, ventricular tachycardia; HF, heart failure; CAD, coronary artery disease.
453
Appropriateness of use criteria for TTE
Table 2
Study classification according to AUC (2011 version) in different clinical settings Appropriate (%)
Uncertain (%)
Inappropriate (%)
P-value
84 87.7
3.6 2.6
11.3 9.7
0.34
94.4 83.1
1.6 3.8
4 13.1
,0.05
Cardiology Cardiothoracic surgery
85.3 60
4.8 0
9.9 40
,0.05
Other medical specialities
89
2.2
8.8
Other surgical specialities GP
80.8 87
0 1.4
19.2 10.8
............................................................................................................................................................................... Tertiary vs. DGH Tertiary Non-tertiary In- vs. out-patients In-patients Out-patients Referring specialty
Table 3
Comparison of echocardiographic findings in different settings Normal (%)
Minor TTE findings (%)
Major TTE findings (%)
P-value
16.1
33.7
50
,0.005
44
40
............................................................................................................................................................................... Speciality of referral consultant Cardiology Cardiothoracic surgery
8
Other medical specialities Other surgical specialities
17.6 21.2
40.2 46.2
41.6 32.7
GP
29.7
36.5
33.8
26.1
41.7
30.4
18.2
21.2
60.6
17.0
37.0
45.7
Appropriate vs. inappropriate studies Inappropriate Uncertain Appropriate Tertiary vs. DGH Tertiary centres
19.5
38.5
41.4
DGH In- vs. out-patients
17.6
36.7
45.4
In-patients Out-patients
9.6
31.7
58.4
21.3
39.9
38.2
differences between specialities in terms of appropriateness of ECHO and showed that outpatient scans were more often inappropriate than scans requested for in-patients, with ‘a routine ECHO follow-up’ in stable patients accounting for most of the inappropriate requests, that appropriate scans, and those requested by cardiologists, yield abnormalities more often than inappropriate scans, and that scans requested by GPs have a high proportion of normal studies. To our knowledge, this is the first study to apply the 2011 AUC criteria to an UK patient population, and only the second to have looked at AUC utilization in Europe In the USA, compliance with AUC is essential: requests for imaging tests are authorized by private health insurance plans only if they comply with ‘radiology benefits manager pre-certification criteria,’
0.004
0.58
,0.005
which are in line with AUC. In the UK NHS and in most European countries, the financial pressures on imaging are also intense, but the link between appropriateness and cost is rarely ‘felt’ by the physicians who order the test, which perhaps helps explain the relative lack of interest for AUC in the European echocardiography community. We think that this is likely to change, as cost-consciousness increases among health-care professionals.
What do we know from previous studies? The first wave of studies assessing the performance of the AUC appeared in the wake of the publication of the first version in 2007.13 – 15 These studies were performed mainly in academic centres and demonstrated that a significant minority of indications
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Numbers are percentages. GP, general practitioner; DGH, district general hospital.
454
Table 4
G. Maria-Magdalena and A. Ionescu
Summary of previous studies that have assessed the clinical application of AUC
Author and year of publication
Number of patients
Setting
AUC version
Comments
Appropriateness of requests for echocardiography (%)
..................................
NC
A
U
I
2011
2
82
7
11
............................................................................................................................................................................... Mansour et al.6
2247 (1553 TTE)
Acad.
Abnormal findings more common in A than in I studies
2007
11
89
0
11
Acad., comm.
2011
2
71
7
22
2007
23
83
0
17
1179
Regnl.
2011
96.5
0.4
2.4
86
0
1
Alqarqaz et al.9
170
Acad.
77
14
9
77
0
9
Parikh et al.7
384
Acad.
92.2
0.5
1.8
86.7
0
0.8
Ballo et al.4
931
Comm., in-pt
2011
1.2
80.3
5
14.7
A and U indications impacted clinical care more often than I ones
Patil et al.8
1820
Acad.
2011
0.4
82
5.3
12.3
Routine surveillance without change in clinical status was the most common I indication
Bhatia et al.5
450
Bailey et al.3
2007
13
2011 14
2011 2007
5.5 12,5
93% of the undefined studies (2007) could be classified using 2011 AUC A studies more likely to show new/major findings resulting in patient care or intervention Revised criteria successful in addressing an increased number of clinical indications
A, appropriate; NC, not classifiable; U, uncertain; I, inappropriate; Acad, academic hospital; Regnl, regional hospital; Comm, community hospital; in-pt, in-patients; OPD, outpatients department.
(between 12 –35%) were not captured by the criteria and were deemed ‘unclassifiable’. Of the remaining studies, around 55–85% were deemed appropriate. It was not clear whether appropriately requested scans were more likely to identify relevant abnormalities than inappropriate ones, as results were divergent between studies. This early experience spurred a process of refining the AUC which produced the revised criteria in 2011. The published experience with these is summarized in Table 4. The revised AUC have virtually eliminated the ‘unclassified’ category of indications (it now represents only around 2% of requests). However, although the proportion of inappropriate scans has increased slightly, to the detriment of appropriate scans, all studies using the revised AUC have found that appropriate indications are more often associated with new, unexpected, or actionable findings than inappropriate ones. Outpatient settings seem more prone to inappropriate indications, and cardiologists ‘get it right’ more often than other specialties, while ‘routine’ ECHO monitoring in the absence of a change in clinical status is the main cause of inappropriate scans.
What does this study show? This is the first study to assess AUC in a large geographical area with a unified and homogenous health-care system (Wales, UK), in the District General Hospitals of various sizes, as well as in two tertiary centres. The proportions of appropriate (86%), inappropriate (11%), and uncertain indications (3%) were similar to the findings of previous studies. The only European study that has applied AUC4 reported that virtually all (98.8%) indications for TTE in 931 patients in five community hospitals were captured by the revised
criteria. Indications were appropriate in 80.3%, inappropriate in 14.7%, and of uncertain appropriateness in 5% of cases. Interestingly, after analysing an independent sample of 259 patients who had been discharged from the hospital during the same period, the authors report that 16.2% fulfilled criteria for being offered a TTE, without one having been requested. The most common inappropriate indication for ECHO for outpatients and inpatients was Indication 35 (‘initial evaluation for a murmur or click when there are no other symptoms or signs of valvular or structural heart disease’) in 29 studies (2.7% from all patients). However, the definition ‘35’ is of dubious clinical relevance. When there is an auscultation evidence for a ‘click’ or murmur from the clinical examination, it is difficult to justify deferral of an echocardiographic study. We found that the highest proportion of inappropriate indications came from cardiac surgeons, who request TTE ‘routinely’ in patients with prosthetic heart valves whenever they are seen in the outpatient department, with little correlation with the clinical status. We confirmed the finding from previous studies that requests for outpatient TTE are more frequently inappropriate than in-patient requests. Inappropriate studies were more often normal than appropriate ones. Indication 1 (‘symptoms related to suspect cardiac aetiology’) was the most frequent reason for requesting an ECHO in outpatients, but its ‘yield’ depends on the clinical skills of the physician referring the patient. Of all patients referred for Indication 1, almost a third had normal scans; half of those referred for this indication by GPs were also normal. This suggests that better targeting of ECHO by
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2007
I: 30% in academic OPD, 21% in community OPD, 14% in academic in-patient setting
Appropriateness of use criteria for TTE
GPs might increase the yield of TTE and reduce the proportion of unnecessary scans.
Limitations The AUC have been developed in the USA, and this is an UK study. However, the methodology of the AUC has been carefully developed, and the revised criteria have been validated extensively, suggesting that their use can be justified outside the USA. The fact that our results are very similar to those reported from the USA and to those of the only European study, to date, also supports the use of AUC in the UK context. Our data collection was based on questionnaires filled in by the participating centres. We did not have access to the full clinical sets of notes for the patients included in this study, so we could not document the ‘downstream’ impact on the echocardiographic findings.
The proportion of appropriate, inappropriate, uncertain, and unclassifiable studies according to the 2011 AUC is similar in Wales, UK, to that reported from the USA and from the only other European study. This suggests that applying the AUC for screening ECHO requests in the UK setting might be feasible. A strict application of AUC has the potential to reduce the total ECHO workload in Wales by 9000 scans/year. Moreover, increasing the proportion of requests for ECHO that originates with cardiologists rather than with primary care physicians can increase the ‘yield’ and effectiveness of ECHO. The net effect of a strict application of AUC on the costs of health care requires a further study. Conflict of interest: This work was supported by a Romanian Society of Cardiology Research Grant.
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2. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR et al. ACCF/ASE/ AHA/ASNC /HFSA/HRS/SCAI /SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography. J Am Soc Echocardiogr 2011;24:229 –67. 3. Bailey S, Mosteanu I, Tietjen P, Petrini J, Alexander J, Keller A. The use of transthoracic echocardiography and adherence to appropriate use criteria at a regional hospital. J Am Soc Echocardiogr 2012;25:1015 –22. 4. Ballo P, Bandini F, Capecchi I, Chiodi L, Ferro G, Fortini A et al. Application of 2011 ACC/ASE appropriateness of use criteria in hospitalized patients referred for transthoracic echocardiography in a community setting. J Am Soc Echocardiogr 2012;25: 589 –98. 5. Bhatia S, Carne D, Picard M, Weiner R. Comparison of the 2007 and 2011 appropriate use criteria for transthoracic echocardiography in various clinical settings. J Am Soc Echocardiogr 2012;25:1162 –9. 6. Mansour I, Razi R, Bhave N, Ward P. Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal and stress echocardiography. J Am Soc Echocardiogr 2012;25:1153 –61. 7. Parikh P, Asheld J, Kort S. Does the revised appropriate use criteria for echocardiography represent an improvement over the initial criteria? A comparison between the 2011 and the 2007 appropriateness of use criteria for echocardiography. J Am Soc Echocardiogr 2012;25:228–33. 8. Patil H, Coggins T, Kusnetzky L, Main M. Evaluation of appropriate use of transthoracic echocardiography in 1820 consecutive patients using the 2011 revised appropriate use criteria for echocardiography. Am J Cardiol 2012;109:1814 –7. 9. Alqarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriateness of use criteria for transthoracic and transesophageal echocardiography. Int J Cardiovasc Imaging 2012;28:1951 – 8. 10. Vijayan S, Khanji M, Ionescu A. Can application of appropriateness of use criteria reduce the workload in a tertiary echocardiographic laboratory? A single centre experience. Eur J Echocardiogr 2011;12(Abstract supplement):i44. 11. Office of National Statistics. http://www.ons.gov.uk (1 March 2013). 12. Kirkpatrick JN, Ky B, Rahmouni HW, Chirinos JA, Farmer SA, Fields AV et al. Application of appropriateness criteria in outpatient transthoracic echocardiography. J Am Soc Echocardiogr 2009;22:53–9. 13. Martin NM, Picard MH. Use and appropriateness of transthoracic echocardiography in an academic medical center: a pilot observational study. J Am Soc Echocardiogr 2009; 22:48 –52. 14. Willens HJ, Go´mez-Marı´n O, Heldman A, Chakko S, Postel C, Hasan T et al. Adherence to appropriateness criteria for transthoracic echocardiography: comparisons between a regional department of Veterans Affairs health care system and academic practice and between physicians and mid-level providers. J Am Soc Echocardiogr 2009; 22:793–9. 15. Ward RP, Krauss D, Mansour IN, Lemieux N, Gera N, Lang RM. American College of Cardiology Foundation/American Society of Echocardiography Comparison of the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria for outpatient transthoracic echocardiography in academic and community practice settings. J Am Soc Echocardiogr 2009;22:1375 –81.
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Conclusions
455
