Two Years of Appropriateness Criteria for Echocardiography: What Have We Learned and What Else Do We Need to Do?

Abstract

As noninvasive cardiovascular imaging has become more sophisticated and accessible, its use has increased steadily. In the United States, according to Medicare data, transthoracic echocardiography (TTE) constitutes a significant proportion of cardiovascular imaging. This modality is used in a variety of clinical settings and provides a great deal of information at virtually no risk to patients. Because TTE is seen as benign and is widely available, the potential for overuse exists. By developing echocardiographic appropriateness criteria (AC), the American College of Cardiology Foundation and the American Society of Echocardiography have provided a framework of broad indications that encompasses many clinical scenarios. The goals of the AC are to provide a rational approach to the use of cardiovascular imaging and to improve patient care and health outcomes in a cost-effective manner. Ideally, AC should help providers moderate their own practice patterns without stifling clinical judgment, reducing if not supplanting the need for external regulation by insurers and other third parties. These are particularly important goals given the current dialogue on health care reform, as it appears that there are many parties that wish to control how imaging is utilized in an effort to reduce costs. AC are different from clinical guidelines. Clinical guidelines describe a comprehensive list of the conditions for which a test is indicated. AC include more selective indications than guidelines, typically those that are most commonly encountered (because these have the largest potential to generate inappropriate studies). Many clinicians might consider a test to be appropriate if it provides important new information and inappropriate if it does not provide any new information. However, in the AC, an appropriate test is defined as ‘‘one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable.’’ This means that the AC may categorize some tests as ‘‘appropriate’’ even though the results simply confirm what is already known, while other tests may be categorized as ‘‘inappropriate’’ even though they do in fact provide new information that might be valuable for patient care. Also, there will be scenarios in which it is uncertain or unclear if a test is appropriate. Because the AC are not all inclusive, some tests will not fit into one of the covered scenarios and thus will be ‘‘unclassifiable.’’ The AC for TTE and transesophageal echocardiography (TEE) were published in July 2007, and those for stress echocardiography ap-