title: Guideline Adherence for Echocardiographic Follow-Up in Outpatients with at Least Moderate Valvular Disease.
abstract: BACKGROUND
  Attention to resource utilization has led to increased scrutiny of the appropriateness of initial diagnostic imaging studies on the basis of current guidelines. Far less attention has been paid to examining the lack of appropriate follow-up studies.
  
  
  METHODS
  A retrospective cross-sectional analysis was performed of 3,781 consecutive outpatients referred for transthoracic echocardiography (TTE) from July to December 2008. Data from the electronic medical records were extracted to see if patients with at least moderate left-sided valvular stenosis or regurgitation underwent subsequent echocardiographic studies within 60 days of the period recommended by the 2006 American College of Cardiology and American Heart Association valve guidelines document.
  
  
  RESULTS
  Of 342 outpatients with at least moderate valve dysfunction, 38 (11%) were excluded for reasons that precluded the need for a follow-up study (e.g. death, surgery). Of the remaining 304 patients, only 179 (59%) underwent follow-up echocardiography within the recommended period. Rates of timely follow-up TTE were higher when ordering physicians were cardiologists or cardiovascular surgeons (65%) compared with primary care physicians or internal medicine specialists (45%) (P < .01). Follow-up rates were significantly different for aortic stenosis (77%), mitral stenosis (67%), aortic regurgitation (49%), and mitral regurgitation (49%) (P < .01). Patients receiving timely follow-up TTE were younger (66 ± 15 vs 71 ± 15 years, P = .002) and more likely to be male (odds ratio, 1.79; 95% CI, 1.12-2.85; P = .01).
  
  
  CONCLUSIONS
  To the authors' knowledge, this is the first study demonstrating low rates of compliance with guideline-recommended monitoring TTE in patients with at least moderate valve dysfunction. Cardiac practitioners have significantly better compliance. Strategies are needed to improve timely follow-up care in this population.
authors.affiliation: Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Raymond H
authors.initials: RH
authors.lastname: Chan
authors.affiliation: Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Jaime L
authors.initials: JL
authors.lastname: Shaw
authors.affiliation: Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Hauser
authors.affiliation: Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Markson
authors.affiliation: Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts. Electronic address: wmanning@bidmc.harvard.edu.
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Manning
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D017548:Echocardiography, Transesophageal / Q000379:methods* / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging*; D006351:Heart Valves / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D010045:Outpatients; D012189:Retrospective Studies; D012720:Severity of Illness Index
keywords: Appropriateness criteria; Echocardiography; Guideline adherence; Surveillance