Appropriateness of Outpatient Echo Requests Within Capital Health

Abstract

BACKGROUND: Increasing use of transthoracic echocardiogram (TTE) studies and repeat echocardiography studies within Canada continues as a rising concern in the face of long wait times. To aid with such a concern, the American Society of Echocardiography (ASE) created the Appropriate Use Criteria to define appropriate and inappropriately ordered echocardiography studies. The objective of this study was to use the ASE criteria to determine the appropriateness of outpatient echocardiography requests within the Halifax Regional Municipality (HRM) in the setting of long wait times and in order to evaluate efficiency. METHODS AND RESULTS: All consecutive adult outpatient transthoracic echo requisitions of studies performed within HRM for the month of November, 2011 were collected. Following collection, the requisitions were divided amongst four clinicians. Each study was evaluated for a number of criteria including a classification of appropriate, uncertain or inappropriate indication as per the 2011 ASE Appropriate Use Criteria. This data was then collected and analyzed using mainly descriptive statistics. During the study period, 98% of the 688 outpatient echocardiograms were collected and 95% of these were matched to an ASE indication. Analysis discovered that 80% were appropriately indicated, 10% uncertainly indicated, and 10% inappropriately indicated. The referrals deemed 'inappropriate' most commonly included: (1) routine surveillance <3 years after valve implantation of prosthetic valve if no suspected valve dysfunction (does not include post-op); (2) routine surveillance <1 year of known cardiomyopathy; (3) routine surveillance<1 year of moderate or severe valve stenosis without a change in status; (4) routine surveillance <3 years of mild valvular regurgitation without change in status; (5) routine surveillance<3 years of mild valvular stenosis without a change in status. CONCLUSION: As medicine continues to advance in its diagnostic capability it is essential to review our systems for proper use in order to maximize system efficiency and minimize health care expenditure. This review was effective in identifying the most common inappropriate referrals for echocardiography within the HRM and creating a baseline for future studies. The results of this study have already been used to change clinical referring practice.