Implementation Of Appropriate Use Criteria Research Articles

How Many Echocardiograms Should be Performed to Detect One Cardiac Abnormality in Patients <18 Years? Results from the “Performing Echocardiography to Detect Heart Disease (PED-HEART) Study”

Introduction: Echocardiography is an important cardiac investigating tool, however, its appropriate use in patients <18 years has to be ascertained. Aim: The aim of this study was to assess the clinical indication of the referral for echocardiography in patients with abnormal and normal echocardiographic examination. Methods: Single-center, retrospective observational analysis was done in patients <18 years who underwent echocardiography. This included patients’ clinical profiles and echocardiography examination findings. Results: Out of 7500 patients, normal echocardiography examinations (Group 1) were found in 75.33% (n = 5650) of the patients. Out of these (Group 1), 32.8% were referred for electrocardiographic changes, while 25% and 31% were for palpitation and chest pain, respectively. Patients with trivial findings on echocardiography were 350 (Group 2). Patients with a significant abnormality on echocardiography requiring medical management (Group 3) or cardiac intervention (Group 4) were 1250 and 250, respectively. The comparison of Group A (combined Groups 1 and 2 patients) with Group B (combined Groups 3 and 4 patients) showed that the referrals made for murmur, suspected heart failure, chest X-ray abnormalities, abnormal blood pressure/shock, and multiple parameters were found to be an independent predictor of abnormal findings on echocardiography. Conclusion: Abnormal findings on echocardiography requiring cardiac intervention in patients <18 years is one in every five echocardiograms performed in this study. The implementation of appropriate use criteria for echocardiography may help in improving this ratio.

Implementation of Appropriate Use Criteria for Transthoracic Echocardiography in Follow-Up Care of Pediatric Patients with Congenital Heart Disease

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. 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. 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). 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.

Abstract 10063: Implementation of Appropriate Use Criteria for Cardiac Computed Tomography and Magnetic Resonance Imaging in the Follow-Up Care of Patients with Conotruncal Congenital Heart Disease

Introduction: To promote the rational use of cardiovascular imaging in the delivery of high-quality and cost-effective care to patients with congenital heart disease (CHD), the American College of Cardiology developed Appropriate Use Criteria (AUC). We aimed to evaluate the appropriateness of indications for cardiac CT and MRI in patients with conotruncal defects and to identify factors associated with Maybe or Rarely Appropriate (M/R) indications. Methods: Twelve US centers contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. Studies were excluded if the patient did not receive primary cardiac care at the center or were not seen &gt; 5 years prior to study date. To account for the nesting of physicians within center, a hierarchical generalized linear mixed model was used to account for center-level variation with physicians nested within center. Results: Of the 1,753 studies (20% CT, 80% MRI) from 12 centers, 16% (range 4-39%) were rated M/R and 2.4% were unclassifiable (Figure 1). Patients age &lt;1 year accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age &lt;1 year (OR 1.9 [95% CI 1.1-3.4]), truncus arteriosus (vs. TOF, OR 2.2 [95% CI 1.2-4.0]), and CT (vs. MRI, OR 2.5 [95% CI 1.7-3.8]). Center-level factors included: part of an adult hospital (vs. stand-alone children’s, OR 0.8 [95% CI 0.2-0.7]) and annual MRI volume (for every 50 unit increase, OR 0.96 [95% CI 0.92-0.99]. Provider-level factors did not remain significant in the multivariable model. Conclusions: Most cardiac CTs and MRIs ordered for the follow-up care of patients with conotruncal defects were rated Appropriate and nearly all were able to be classified. However, there was significant center-level variation and higher annual MRI volume was independently associated with lower odds of M/R rating. These findings inform future quality improvement initiatives.

Abstract 210: Implementation of Appropriate Use Criteria for Cardiology Tests and Procedures: A Systematic Review and Meta-analysis

Background: The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. Methods: We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The analysis protocol was submitted a priori to the PROSPERO international prospective register of systematic reviews. We used a structured data extraction spreadsheet for elements such as study design, implementation strategy, and primary outcome. Results: We included 18 studies, the majority used pre/post cohort designs; few (n=3) were randomized trials. Most studies used multiple strategies (n=12, 66.7%). Education was the most common individual intervention strategy (n=13, 72.2%), followed by audit &amp; feedback (n=8, 44.4%) and computerized physician order entry (CPOE) (n=6, 33.3%). No studies reported on formal use of stakeholder engagement or “nudges”. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95 % confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. Conclusions: We found most published efforts to implement AUC succeeded at reducing inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies.

Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis.

The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or 'nudges'. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.

Assessment of barriers and facilitators in the implementation of appropriate use criteria for elective percutaneous coronary interventions: a qualitative study

BackgroundThe use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness.MethodsAll hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC.ResultsSpecific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography.ConclusionsThe identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.

Widespread Implementation of Appropriate Use Criteria for Cardiac Imaging-Which Are "Appropriate"?

For more than a decade, organizations such as the American College of Radiology (ACR) and theAmericanCollege of CardiologyFoundation(ACCF)havepublishedcriteriadelineatingthe appropriateuseofcardiac imaging.Thesespecialtysocietyguidancedocumentsaredesigned toprovideclinicianswith recommendations regarding the use of imaging and are focused on reducing unnecessary and inappropriate testing. In general,boththeACRandACCFusesimilarmethods in theconstructionof appropriateusecriteria (AUC), byperformingcarefulevidencereviewsandprovidingastandardizedratingofmultiple clinical indications by the use of the UCLA/RAND methodologywithamodifiedDelphiapproach.1However, substantial methodological differences exist between each organization’s approach to AUC, including the ACCF’s greater relianceof riskstratificationbasedonclinical factors,whichresults in a far greater specificity of clinical indicationswith theACCF version.Furthermore, thehierarchicalnatureof theACCFAUC readily lend these criteria to be adopted into clinical decision support tools.1 In this issue of JAMA Cardiology, Winchester et al2 compare2setsofappropriateusecriteria,onederivedfromtheACR and the other led by the ACCF. Substantial discordance in appropriatenesscategorizationwasnoted(22.3%),andmorecomplete “coverage” of all clinical situations was demonstrated with the ACCF AUC. A significant limitation of this article relates to theuseofanolderversionof theACCFAUC.This singlemodality set ofAUCwaspublished7years ago3 andhas largely been superseded by the 2013 multimodality AUC,4 which should serve as the current standard for the evaluation of appropriateuse.Whilemany indicationswereratedsimilarlywith regard to radionuclide imaging, several important differences in appropriateness classificationwere noted, including the appropriateness of radionuclide imaging after CABG, the value inhigh-risk asymptomatic individuals, and its use in the preoperative assessment of patients before intermediate-risk surgery.5 A concern raised by Winchester et al2 is the finding that there were far more abnormal imaging studies or individuals with ischemiawithan inappropriatedesignation fromtheACR (35.4%and 17.5%, respectively) thanwith theACCFAUC (7.3% and2.6%, respectively).Although it iswelldescribed that studies designated as inappropriate may still have abnormal test results, as reported in6 trials,5 the fact that the frequencymay be higher using the ACR criteria is worrisome. Another important consideration related to theuseofAUC ishowoften testing for inappropriate indicationsprovidesusefulprognostic information, thuspotentially supporting the recommendation not to perform a test for an inappropriate indication.Dataarenowbecomingavailable, includingstudiessuch as thosebyDoukkyetal,6whichdemonstrate that the truepredictive power of radionuclide imaging regarding the identification of patients at risk for a subsequent cardiac event lies in thepopulationwhoundergoappropriate testing, notwhen radionuclide imaging is applied for inappropriate indications.To myknowledge,nosuchdatahavebeenprovidedusing theACR criteria, and based on the discrepancies between the 2 sets of AUCandthesubstantiallyhigher incidenceofabnormal singlephotonemissioncomputed tomographystudiesperformedfor ACR inappropriate indications, it seems reasonable to conclude that theremay be performance issues related to the use of the ACR criteria for this purpose. It is critical to recognize that the mere creation of these AUC, regardless of the source, is almost certainly insufficient to promote change in utilization. It must first be shown that the levels of appropriateuse can successfully be trackedusing a specific set of AUC, so as to demonstrate current performance and permit initiatives to be developed to improve imaging utilization. Notably, there are multiple publications demonstrating the feasibility of tracking AUC using the ACCF criteria but very limited literature regarding theuseof theACR AUC. Publications over the last 10 years, which includemore than 20000 patients, have revealed that appropriate utilizationof cardiac imagingmaybe successfully assessedusing the ACCF AUC,5 with very few gaps in appropriateness determination through the entire spectrum of patient presentations. Furthermore, tools must be available to place this valuable information directly in the hands of the clinician and ideally provideguidanceat thetimeof testordering.Thishasnowbeen shown in several cohorts using the ACCF AUC.7,8 Despite efforts to promote utilization of AUC and encourage practitioners to be mindful of utilization patterns, neither set of AUC has been fully incorporated into clinical practices, and are incompletely used by radiology benefits managers, who often develop their own, non–providerbased criteria. Theopportunities providedbyAUC implementation appear great and offer situations for tracking provider practice to support continuous quality improvement and to provide education for active practitioners and trainees alike. Recent federal legislation will undoubtedly alter the current landscape and may impact whether published, adjudicated AUC are fully implemented by all payers. The Protecting Access to Medicare Act of 2014 (which became law on April 1, 2014)mandates the use of AUC for advanced cardiac imaging, including nuclear cardiology, cardiac magnetic resonance, and cardiac computed tomography, for all Medicare beneficiaries.9 The current program by the Centers for Medicare &Medicaid Services (CMS) requires the selection of a provider-led entity’s AUC and the subseRelated article page 207 Appropriate Use Criteria for Cardiac Imaging Brief Report Research

Reducing Radiation Exposure from Cardiovascular Imaging Through Implementation of Appropriate Use Criteria

Cardiac imaging is a key instrument in the evaluation of patients with known or suspected coronary artery disease. Although clear benefits accompany the use of nuclear cardiology and cardiac CT techniques, is well-documented in the medical literature, there is growing concern about the risk related to exposure to ionizing radiation. Although the true impact of low-level ionizing radiation is often poorly characterized, clinicians and medical organizations encourage minimization of exposure, with a focus on a balance between benefits and risks of cardiac imaging procedures. The appropriate use criteria (AUC), developed by the American College of Cardiology Foundation, American Heart Association, and multiple other societies, provide guidance regarding test utilization and assist in optimizing an approach involving the right test for the right patient at the right time. By reducing inappropriate use of cardiac CT and radionuclide imaging, exposure to unnecessary ionizing radiation may be minimized. Evaluation of appropriateness allows for practitioners to monitor their performance and serves to provide focus for educational efforts related to inappropriate test indications. Several key areas, including test layering and the use of serial imaging in asymptomatic patients likely contribute to inappropriate use and increased radiation exposure. Therefore, the use of AUC, in conjunction with other radiation dose reduction efforts, promotes significant improvement in patient safety.