Pediatric Appropriate Use Criteria Implementation Project: A Multicenter Outpatient Echocardiography Quality Initiative.
BACKGROUND
Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability.


OBJECTIVE
This study sought to determine the appropriateness of TTE as currently performed in pediatric cardiology clinics, diagnostic yield of TTE for various AUC indications, and any gaps in the AUC document.


METHODS
Data were prospectively collected from patients undergoing initial outpatient TTE in 6 centers. TTE indications (appropriate [A], may be appropriate [M], or rarely appropriate [R]) and findings (normal, incidental, or abnormal) were recorded.


RESULTS
Of the 2,655 studies ordered by 102 physicians, indications rated A, M, and R were found in 1,876 (71%), 316 (12%), and 319 studies (12%), respectively, and 144 studies (5%) were unclassifiable. Twenty-four of 113 indications (21%) were not used. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for 75% of indications rated R. Pathologic murmur had the highest yield of abnormal findings (40%). Odds of an abnormal finding in an A or M TTE were 6 times that of R (95% confidence interval [CI]: [2.8 to 12.8]). Abnormal findings were more common in patients <1 year of age than in those >10 years of age (odds ratio: 6.4; 95% CI: 4.7 to 8.7). Age was a significant predictor of an abnormal finding after adjusting for indication and site (p < 0.001).


CONCLUSIONS
Most TTEs ordered in pediatric cardiology clinics were for indications rated A. AUC ratings successfully stratified indications based on the yield of abnormal findings. This study identified differences in the yield of TTE based on patient age and most common indications rated R. These findings should inform quality improvement efforts and future revisions of the AUC document.
Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia. Electronic address: sachdevar@kidsheart.com.
Ritu
R
Sachdeva
American College of Cardiology, Washington, DC.
Joseph
J
Allen
Massachusetts General Hospital, Boston, Massachusetts.
Oscar J
OJ
Benavidez
Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
Robert M
RM
Campbell
Duke University, Durham, North Carolina.
Pamela S
PS
Douglas
Mayo Clinic, Rochester, Minnesota.
Benjamin W
BW
Eidem
American College of Cardiology, Washington, DC.
Lara
L
Gold
Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
Michael S
MS
Kelleman
Miami Children's Hospital, Miami, Florida.
Leo
L
Lopez
Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
Courtney E
CE
McCracken
Children's Hospital at Montefiore, New York, New York.
Kenan W D
KW
Stern
Massachusetts General Hospital, Boston, Massachusetts.
Rory B
RB
Weiner
Miami Children's Hospital, Miami, Florida.
Elizabeth
E
Welch
Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York.
Wyman W
WW
Lai
D000553:Ambulatory Care / Q000706:statistics & numerical data; D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging*; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004452:Echocardiography / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D016017:Odds Ratio; D010045:Outpatients / Q000706:statistics & numerical data; D061214:Patient Safety; D010372:Pediatrics; D011786:Quality Control; D018570:Risk Assessment; D014600:Utilization Review
echocardiography; outpatient; pediatric cardiology