Abstract 16645: Comparison of Primary Care Providers and Pediatric Cardiologists in the Appropriateness Use Criteria and Associated Cost Differences for Outpatient Pediatric Echocardiograms

Abstract

Introduction: Appropriate use criteria (AUC) have been established for the transthoracic echocardiogram (TTE) in pediatric cardiology, but, in many labs, echocardiograms can be ordered by the primary care provider (PCP). There is limited data comparing appropriateness between pediatric cardiologists and PCPs and the associated costs of rarely appropriate echocardiograms. Hypothesis: Pediatric cardiologists order less rarely appropriate TTEs and have a lower proportion of cost attributed to rarely appropriate studies. Methods: Patients with initial outpatient pediatric or congenital TTE ordered by a pediatric cardiologist or PCP and interpreted at our institution from November 2016 to October 2017 were included. Appropriateness of TTE indications were classified as appropriate, maybe appropriate, rarely appropriate, and unclassifiable. TTE findings were classified as normal, incidental or abnormal. TTE cost was estimated using the Healthcare Bluebook. The sum cost of rarely appropriate TTEs was divided by total number of patients in each group (pediatric cardiologists vs. PCPs). Data was compared using chi-squared testing. Results: 311 pediatric cardiology and 193 PCP patients were included for analysis. Two percent of pediatric cardiology and 18% of PCP TTE indications were unclassifiable. Of those classified, pediatric cardiologists had a higher rate of appropriate TTEs compared to PCPs (69% vs. 35%; p<0.001) and lower rate of rarely appropriate TTEs (17% vs. 62%; p<0.001). Abnormalities were present in 13% of TTEs ordered by pediatric cardiologists compared to 3% ordered by PCPs (p<0.001). Based on cost of $526 per TTE, $326 per patient was attributed to rarely appropriate indications when ordered by PCPs compared to $90 per patient for pediatric cardiologists. This cost difference decreases substantially when taking referral and ECG costs into account ($326 vs $273). Conclusions: PCPs order more rarely appropriate TTEs, and subsequently have a higher cost incurred per TTE for rarely appropriate indications. However, this cost difference decreases substantially when taking into account referral and ECG costs. Therefore, PCP education of the AUC would have a significant impact in reducing cost for rarely appropriate indications.