title: Impact of a structured referral algorithm on the ability to monitor adherence to appropriate use criteria for transthoracic echocardiography.
abstract: BACKGROUND
  Many free-form-text referral requisitions for transthoracic echocardiography (TTE) provide insufficient information to adequately evaluate their adherence to Appropriate Use Criteria (AUC). We developed a structured referral requisition algorithm based on requisition deficiencies identified retrospectively in a derivation cohort of 1303 TTE referrals and evaluated the performance of the algorithm in a consecutive series of cardiology outpatient referrals.
  
  
  METHODS
  The validation cohort comprised 286 consecutive TTE outpatient cardiology referrals over a 2-week period. The relevant AUC indication was identified from information extracted from the free-form-text requisition. The structured referral algorithm was applied prospectively to the same cohort using information from the free-form-text requisition, electronic medical record and ordering clinicians. Referrals were classified as appropriate, uncertain, non-adherent (inappropriate) or unclassifiable based on the American College of Cardiology Foundation 2011 AUC.
  
  
  RESULTS
  Only 28.7 % of free-form-text requisitions provided adequate information to identify the relevant AUC indication, as compared to 94.4 % of referrals using the structured referral algorithm (p < 0.001). The structured algorithm improved identification in the AUC categories of general evaluation of cardiac structure/function (100 % vs. 43.0 %, p < 0.001); valvular function (100 % vs. 23.0 %, p < 0.001); hypertension, heart failure or cardiomyopathy (100 % vs. 20.3 %, p < 0.001); and adult congenital heart disease (100 % vs. 0 %, p < 0.001). By applying the algorithm, the number of identifiable non-adherent studies increased from 2.6 to 10.4 % (p <0.001).
  
  
  CONCLUSIONS
  Use of a structured TTE referral algorithm, as opposed to a free-form-text requisition, allowed the vast majority of referrals to be monitored for AUC adherence and facilitated the identification of potentially inappropriate referrals.
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Promislow
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Abunassar
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Behnam
authors.initials: B
authors.lastname: Banihashemi
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Chow
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Girish
authors.initials: G
authors.lastname: Dwivedi
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
authors.forename: Kasra
authors.initials: K
authors.lastname: Maftoon
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada. iburwash@ottawaheart.ca.
authors.forename: Ian G
authors.initials: IG
authors.lastname: Burwash
mesh_terms: D000368:Aged; D000465:Algorithms; D002318:Cardiovascular Diseases / Q000175:diagnosis*; D004452:Echocardiography / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods*; D018579:Patient Selection; D012017:Referral and Consultation; D015203:Reproducibility of Results; D012189:Retrospective Studies
keywords: Appropriate use criteria; Diagnostic requisitions; Quality improvement; Transthoracic echocardiography