Advertisement

Impact of Clinician Engagement on Implementation of the Pediatric Echocardiography Appropriate Use Criteria

  • 35 Accesses

Abstract

We sought to determine whether awareness of the pediatric appropriate use criteria (AUC) affected transthoracic echocardiogram (TTE) ordering by cardiologists; evaluate for differences in classification of an encounter’s AUC clinical scenario by investigator chart review compared with clinicians at the time of the encounter; and assess TTE yield by appropriateness rating. AUC clinical scenario(s) were assigned to patients without prior TTE by investigator chart review of visits in 2014 (n = 209) and 2016 (n = 199), and by clinician classification in 2016 (n = 671). Investigators documented TTE utilization and findings. Between 2014 and 2016, TTE utilization decreased from 54 to 33% (p < 0.001) of “rarely appropriate” (R) encounters, resulting in a decrease in overall TTE utilization from 73 to 55% of encounters (p < 0.001). There was only moderate agreement of AUC appropriateness by investigator chart review and clinician classification (κ = 0.533, p < 0.001). Abnormal TTE findings were detected in 18.7% of R encounters, with 21 of 24 abnormalities in infants younger than 4 months presenting with murmur. A decrease in TTE utilization for R encounters may represent a change in practice from increased awareness of the AUC. AUC scenario classification by clinicians at the time of the encounter could be superior to chart review. TTE abnormalities may be missed in infants younger than 4 months of age when evaluated for murmurs with the AUC.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2

Abbreviations

A:

Appropriate

AUC:

Appropriate use criteria

M:

May be appropriate

OR:

Odds ratio

R:

Rarely appropriate

REDCap:

Research electronic data capture

TTE:

Transthoracic echocardiogram

References

  1. 1.

    Lucas FL, DeLorenzo MA, Siewers AE, Wennberg DE (2006) Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993–2001. Circulation 113(3):374–379. https://doi.org/10.1161/CIRCULATIONAHA.105.560433

  2. 2.

    Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED, Wolk MJ, Allen JM, Raskin IE (2005) ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 46(8):1606–1613. https://doi.org/10.1016/j.jacc.2005.08.030

  3. 3.

    Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R (2014) ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol 64(19):2039–2060. https://doi.org/10.1016/j.jacc.2014.08.003

  4. 4.

    Sachdeva R, Allen J, Benavidez OJ, Campbell RM, Douglas PS, Eidem BW, Gold L, Kelleman MS, Lopez L, McCracken CE, Stern KW, Weiner RB, Welch E, Lai WW (2015) Pediatric appropriate use criteria implementation project: a multicenter outpatient echocardiography quality initiative. J Am Coll Cardiol 66(10):1132–1140. https://doi.org/10.1016/j.jacc.2015.06.1327

  5. 5.

    Rose-Felker K, Kelleman MS, Campbell RM, Oster ME, Sachdeva R (2016) Appropriate use and clinical impact of echocardiographic "evaluation of murmur" in pediatric patients. Congenit Heart Dis 11(6):721–726. https://doi.org/10.1111/chd.12379

  6. 6.

    Kourtidou S, Evers PD, Jorgensen NW, Kronmal RA, Lewin MB, Schultz AH (2017) Pediatric appropriate use criteria for outpatient echocardiography: practice variations among pediatric cardiologists, noncardiologist subspecialists, and primary care providers. J Am Soc Echocardiogr 30(12):1214–1224. https://doi.org/10.1016/j.echo.2017.08.014

  7. 7.

    Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KW, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW (2016) Effect of release of the first pediatric appropriate use criteria on transthoracic echocardiogram ordering practice. Am J Cardiol 118(10):1545–1551. https://doi.org/10.1016/j.amjcard.2016.08.019

  8. 8.

    Chamberlain RC, Pelletier JH, Blanchard S, Hornik CP, Hill KD, Campbell MJ (2017) Evaluating appropriate use of pediatric echocardiograms for chest pain in outpatient clinics. J Am Soc Echocardiogr 30(7):708–713. https://doi.org/10.1016/j.echo.2017.03.008

  9. 9.

    Pelletier JH, Blanchard S, Chamberlain RC, Hornik CP, Campbell MJ, Hill KD (2017) The use of echocardiography for pediatric patients presenting with syncope. J Pediatr 190:43–48. https://doi.org/10.1016/j.jpeds.2017.07.010

  10. 10.

    Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KWD, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW (2017) Educational intervention for improving the appropriateness of transthoracic echocardiograms ordered by pediatric cardiologists. Congenit Heart Dis 12(3):373–381. https://doi.org/10.1111/chd.12455

  11. 11.

    Stern KWD, Gulesserian T, Choi J, Lang SM, Statile CJ, Michelfelder EC, McLaughlin ES, Nguyen T, Lopez L, Verghese GR, Hsu DT, Sachdeva R (2017) Factors influencing pediatric outpatient transthoracic echocardiography utilization before appropriate use criteria release: a multicenter study. J Am Soc Echocardiogr 30(12):1225–1233. https://doi.org/10.1016/j.echo.2017.08.015

  12. 12.

    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381. https://doi.org/10.1016/j.jbi.2008.08.010

Download references

Acknowledgements

We thank Daniel Saurers, RDCS, for creating the project interface with the echocardiography database.

Funding

MSR and ANL were supported by the National Heart, Lung, and Blood Institute (T32HL105334). Project REDCap was supported by the National Center for Advancing Translational Sciences (CTSA award UL1TR000445).

Author information

Correspondence to Markus S. Renno.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Renno, M.S., Lambert, A.N., Kannankeril, P. et al. Impact of Clinician Engagement on Implementation of the Pediatric Echocardiography Appropriate Use Criteria. Pediatr Cardiol (2020). https://doi.org/10.1007/s00246-020-02284-4

Download citation

Keywords

  • Pediatric
  • Appropriate use criteria
  • Transthoracic echocardiography
  • Resource utilization
  • Quality improvement