Appropriate Use and Clinical Impact of Echocardiographic "Evaluation of Murmur" in Pediatric Patients.
OBJECTIVE
To determine the appropriateness and yield of transthoracic echocardiograms (TTE) for murmur evaluation based on the pediatric Appropriate Use Criteria (AUC) and study the influence of patient age and physician experience on TTE appropriateness, yield, and ordering frequency.


METHODS
Retrospective review of medical records of patients referred to our practice for murmur evaluation from April to September 2014. Data collected included indication for TTE, patient age, physician experience since fellowship, TTE findings and exit diagnosis. Appropriateness was assigned based on the AUC document.


METHODS
Pediatric cardiology clinics affiliated with a large pediatric cardiology practice.


METHODS
One thousand seven hundred one consecutive patients (≤ 18 years) referred to our practice for murmur evaluation.


METHODS
Not applicable OUTCOME MEASURES: The primary outcome was appropriateness of TTE orders. The secondary outcomes were the yield of abnormal TTE findings and the influence of patient age and physician experience on appropriateness, yield, and frequency of ordering TTEs.


RESULTS
Of the 1701 patients referred for a murmur, 526 (30.9%) had a TTE [441/526 (83.8%) Appropriate; 85/526 (16.2%) Rarely Appropriate]. Abnormal findings were present in 130/441 rated Appropriate and none rated Rarely Appropriate. Infants <3 months had the highest rate of TTEs rated Appropriate and the highest yield of abnormal findings. Physicians with >20 years of experience not only had the lowest TTE ordering rate but also the lowest appropriateness rate with no difference in the yield of abnormal findings.


CONCLUSIONS
Most TTEs ordered for murmur were for indications rated Appropriate. Abnormal findings were present in one-fourth and only those rated Appropriate. Patient age and physician experience can significantly influence TTE utilization. This information is helpful in designing quality initiatives to optimize TTE utilization for murmur evaluation.
Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.|Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga, USA.
Kirsten
K
Rose-Felker
Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga, USA.
Michael S
MS
Kelleman
Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.|Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga, USA.
Robert M
RM
Campbell
Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.|Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga, USA.
Matthew E
ME
Oster
Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.|Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga, USA.
Ritu
R
Sachdeva
D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence; D004452:Echocardiography / Q000706:statistics & numerical data*; D006337:Heart Murmurs / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D007223:Infant; D008499:Medical Records; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D011379:Prognosis; D019984:Quality Indicators, Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D019564:Unnecessary Procedures
Appropriate Use Criteria; Echocardiogram; Murmur; Pediatrics