Background: Overutilisation of transthoracic echocardiography (TTE) and increase in other cardiovascular testing have led the American College of Cardiology Foundation and the American Society of Echocardiography to develop indications for the appropriate use of cardiovascular imaging known as the Appropriate Use Criteria (AUC). It is estimated that approximately 10–15% of TTEs are not indicated and up to 30% of these tests ordered by primary care practitioners could have been avoided. This approach is important to limit unnecessary and costly echocardiograms.
Methods: We performed a chart review and data analysis of all patients who had primary discharge ICD10 code of heart failure (HF) between 1 June 2016 and 30 June 2017. The data were obtained from the Phoenix Veterans Administration (VA) Hospital corporate database. Observational status was excluded. These patients were subdivided into HF and readmissions for HF defined as hospitalisation within 1 year of the initial discharge.
The clinical indications for requesting TTE were obtained from the echo orders and the electronic medical record. The patient’s signs and symptoms on admission were evaluated, as well as the stated reasons that led to the echo study. The indications for these tests were designated as appropriate, inappropriate or uncertain, based on the AUC guidelines. The clinical scenarios that were deemed inappropriate for repeat echocardiogram orders included patients with HF exacerbation that had a clear precipitant (i.e. medication non-compliance), no change in clinical presentation or routine surveillance.
Results: There were 51 patients with HF readmissions. Of these, 16 had repeat echocardiograms within 1 year. Of these 16 patients, nine met the criteria for inappropriate use. This is 56% of repeat TTEs in patients with HF readmissions. The majority of inappropriate use, accounting for 66%, was due to the patient having no change in symptomatology, while 33% had clear precipitating aetiologies. Half of the patients had reduced ejection fraction (<55%), while the other half had preserved ejection fraction (>55%). The average repeat echo was 3 months.
Conclusion: HF is one of the most common causes for hospitalisation in older patients. Rehospitalisation for HF is associated with increased mortality and contributes to rising healthcare costs. TTE represents the first-line cardiovascular imaging modality for the assessment of patients with HF. Other imaging modalities are an alternative, particularly if the patient has suboptimal windows on echocardiogram. There are no long-term studies or clear guidelines to determine correct utilisation of TTE in HF readmissions. This quality-improvement study sheds light on TTE overutilisation and provides an opportunity to reduce cost and avoid unnecessary procedures.
Over the years, initiatives, such as AUC and the Choosing Wisely campaign, have focused attention on the overreliance on procedures and tests. It is evident from the literature that education can decrease the rate of inappropriate ordering of tests. The interventional strategies range from passive to active, but certain measures have had encouraging results. One instrument is use of a point-of-care-decision support tool in the electronic medical record that can improve ordering when indicated and limit frequency by prompting the physician. Another approach is to study patient outcome and mortality related to the number of imaging procedures. Further studies and research are needed to determine whether applying the AUC guidelines achieves these goals.
In future, data can be extrapolated to correlate physical examination findings with imaging results, such as change in the jugular venous pulse amplitude. Additionally, AUC validity can be further evaluated in patients with reduced versus preserved left ventricular function, or those with specific complications, such as those with valvular heart disease. TTE is an important cardiovascular imaging tool and is cost-effective when it is clinically goal-directed with the history and physical examination.
The AUC was designed to guide clinicians to appropriately order imaging tests that affect the management of the patient. Therefore, routine testing with TTE when there is no change in the clinical status is not indicated. The quality-improvement project focuses on HF readmissions and the use of echocardiography at the Phoenix VA. Limitations of the study include one resident physician observation when it would be preferable to have multiple physicians evaluate the indications separately to see if there is disagreement.