Evaluating Appropriate Use of Pediatric Echocardiograms for Chest Pain in Outpatient Clinics

Abstract

Echocardiography is often used in the evaluation of pediatric chest pain, but the incidence of cardiac pathology is low. In 2014, the American College of Cardiology published appropriate use criteria (AUC) forechocardiography including recommendations for pediatric chest pain. We evaluated the frequency and diagnostic yield of echocardiograms performed for each AUC indication and cost associated with echocardiograms performed for indications meeting the "rarely appropriate" criteria. Retrospective, single-institution study of all patients 18years or younger undergoing an initial evaluation for chest pain by a pediatric cardiologist (2014-15). We categorized the appropriateness of indications for echocardiograms on the basis of the AUC. We used multivariable logistic regression to determine factors associated with performance of an echocardiogram with the "rarely appropriate" indication. Excess costs associated with nondiagnostic echocardiograms meeting the "rarely appropriate" criteria were estimated using the Healthcare Bluebook to estimate a fair market price. The cohort included 539 patients, median age 13years (range, 3-18) and 51.0% female. With retrospective application of the AUC, echocardiogram indications were classified as "appropriate" (304/539, 56.4%), "maybe appropriate" (68/539, 12.6%), and "rarely appropriate" (167/539, 31.0%). Echocardiograms were performed in 70.5% (380/539) of patients overall and in 35.9% (60/167) of patients with "rarely appropriate" indications. Of those undergoing echocardiography, abnormal findings were present in 5.0%(19/380) and incidental findings in 2.6% (10/380); however, only one echocardiogram (0.3%) led to a diagnosis considered to be contributory to the patient's chest pain. There were no abnormal findings in the "rarely appropriate" subgroup. Provider use of echocardiography for "rarely appropriate" indications varied widely from 0 to 75% across 15 providers (P=.004). In multivariable analysis, provider clinical experience of ≥20years was associated with a lower rate of echocardiograms for "rarely appropriate" indications (odds ratio, 0.21 [95% CI, 0.09-0.47] vs. providers with <10years' experience, P<.001). There was no significant association between race, ethnicity, age, sex, payer status, or total number of patients seen and performance of an echocardiogram meeting the "rarely appropriate" indications. Echocardiograms with "rarely appropriate" indications resulted in $47,578 in excess costs over the 1-year study. Echocardiogram use in patients meeting the "rarely appropriate" indication criteria is of little diagnostic utility and contributes to additional cost to the patient and health care system.