title: Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice.
abstract: Pediatric appropriate use criteria (AUC) were recently published for initial outpatient transthoracic echocardiography (TTE). The purpose of this study was to determine the effect of AUC publication on TTE ordering patterns of pediatric cardiologists. Data were prospectively collected on patients who had initial outpatient TTE ordered before (phase I, April to September 2014) and 3 months after (phase II, January to April 2015) AUC document publication at 6 centers. Site investigators assessed each study's indication and assigned AUC appropriateness as "appropriate" (A), "may be appropriate" (M), "rarely appropriate" (R), or "unclassifiable." One hundred three physicians ordered 4,562 TTEs (2,655 phase I and 1,907 phase II). Overall, there was no statistically significant change in the proportion of A, M, or unclassifiable, but R decreased (12.0% to 9.6%, p = 0.01). There was significant variability among the centers in the percentage of studies for indications rated R (4.9% to 34.8%). There was no significant change in any of the appropriateness ratings at 4 centers, a decrease in R and an increase in A at 1 and a decrease in R and increase in unclassifiable at another. The first pediatric AUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. There was a significant variability in appropriateness of studies among centers. These data suggest that active educational interventions are required to substantially improve the appropriate use of pediatric TTE in the outpatient setting.
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia. Electronic address: sachdevar@kidsheart.com.
authors.forename: Ritu
authors.initials: R
authors.lastname: Sachdeva
authors.affiliation: Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.affiliation: Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Kelleman
authors.affiliation: Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Courtney E
authors.initials: CE
authors.lastname: McCracken
authors.affiliation: Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida.
authors.forename: Leo
authors.initials: L
authors.lastname: Lopez
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, New York, New York.
authors.forename: Kenan W D
authors.initials: KW
authors.lastname: Stern
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, Mayo Clinic Rochester, Rochester, Minnesota.
authors.forename: Benjamin W
authors.initials: BW
authors.lastname: Eidem
authors.affiliation: Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Oscar J
authors.initials: OJ
authors.lastname: Benavidez
authors.affiliation: Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Rory B
authors.initials: RB
authors.lastname: Weiner
authors.affiliation: Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Welch
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Campbell
authors.affiliation: Division of Pediatric Cardiology, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, New York.
authors.forename: Wyman W
authors.initials: WW
authors.lastname: Lai
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006330:Heart Defects, Congenital / Q000175:diagnosis*; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D011786:Quality Control; D013997:Time Factors; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D014600:Utilization Review