Clinical Investigations
Enhancing Quality In Pediatric Echocardiography
Implementation of Appropriate Use Criteria for Transthoracic Echocardiography in Follow-Up Care of Pediatric Patients with Congenital Heart Disease

https://doi.org/10.1016/j.echo.2022.04.016Get rights and content

Highlights

  • This is the first study of outpatient TTE in follow-up care of pediatric patients.

  • Three quarters of TTE is for follow-up of CHD (50% unrepaired).

  • Over 95% of orders for follow-up of CHD were for indications rated appropriate.

  • M and R ratings were associated with simple CHD.

Background

Indications for transthoracic echocardiography (TTE) from the 2020 Appropriate Use Criteria (AUC) for congenital heart disease (CHD) were incorporated into the institutional electronic ordering system as a clinical decision support tool. The purpose of this study was to evaluate the utilization of TTE and factors affecting the appropriateness of orders for TTE during follow-up care of patients with CHD.

Methods

All transthoracic echocardiographic studies performed during follow-up clinic visits from May 1, 2020, to November 30, 2020, were included. Indications for TTE were rated appropriate, may be appropriate, or rarely appropriate on the basis of the AUC and unclassifiable if the indication was not in the document but related to included lesions. CHD was graded as simple, moderate, or complex on the basis of the Bethesda classification. Logistic regression was used to determine the association of ratings with patient age, insurance status, CHD complexity, and clinician experience and specialty.

Results

Of the 5,158 studies, 3,979 (77.2%) were for CHD included in the AUC document, 322 (8%) were unclassifiable, 37 (0.7%) were for CHD not in the document, and 1,142 (22.1%) were for non-CHD indications. Of the 3,657 transthoracic echocardiographic examinations to which AUC ratings could be applied, 95.6% were rated appropriate, 2.4% may be appropriate, and 2.0% rarely appropriate. The highest utilization of TTE was for follow-up of ventricular septal defects, left ventricular outflow tract obstruction, and single ventricles; 46% for unrepaired CHD; 78% for routine surveillance; and the remaining for changes in clinical status. On multivariable analysis, the only significant factor associated with may be appropriate and rarely appropriate ratings was simple CHD (odds ratio, 11.58; 95% CI, 5.36 – 24.98; P < .001).

Conclusions

Three quarters of transthoracic echocardiographic studies ordered during follow-up care in pediatric cardiology clinics are for indications related to CHD. Most examinations for follow-up of CHD were for routine surveillance and indications rated appropriate. Orders for TTE for may be appropriate and rarely appropriate ratings were associated with simple CHD. Although the 2020 AUC document successfully stratifies the majority of indications related to CHD, future documents should consider the unclassifiable CHD indications and the non-CHD indications.

Section snippets

Methods

The study was approved by the institutional review board at Children's Healthcare of Atlanta. Indications for TTE from the 2020 CHD AUC document were incorporated into the EMR ordering system (EPIC) in May 2020 to promote the use of AUC in routine clinical work flow. Physicians in our clinics provide specific AUC indications to sonographers after they have seen patients, and then the sonographers enter the indications into the EMR. Physicians use laminated cards for the 19 color-coded tables in

Results

During the study period, a total of 5,158 transthoracic echocardiographic examinations were ordered by 44 clinicians (41 physicians and three nurse practitioners) for follow-up care in our clinics in patients <18 years of age. Of the 5,158 studies, 3,979 were for CHD indications included in the 2020 CHD AUC document, 37 were for CHD lesions not included in the document, and 1,142 were for non-CHD indications (Table 1). Of the 3,979 indications for CHD, 88% were for indications rated A, 2% for

Discussion

To our knowledge, this is the first study analyzing the appropriateness of TTE in follow-up care of pediatric patients with CHD on the basis of the 2020 CHD AUC document. Using this document, we were able to successfully stratify the majority of transthoracic echocardiographic studies for follow-up of CHD, and the vast majority of studies were for indications rated A. The study also provides a broad perspective on the utilization of TTE for follow-up care in pediatric patients and shows that

Conclusion

Our study shows that majority of transthoracic echocardiographic examinations performed for follow-up care of CHD were for indications rated A on the basis of the 2020 AUC document. Although 75% of studies performed for follow-up care in our clinics were for patients with CHD, the other 25% were for non-CHD indications. Simple CHDs were associated with higher use of indications rated M or R, and a large proportion of those rated R were misclassified. Although further education to improve

Acknowledgment

We thank Ms. Deborah Whitaker (Sibley Heart Center) for her help in extracting the data for this study.

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Conflicts of Interest: None.

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