Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope.
BACKGROUND
Syncope is a common reason for outpatient transthoracic echocardiography (TTE). We studied the applicability of pediatric appropriate use criteria (AUC) on initial outpatient evaluation of children (≤18 years) with syncope.


METHODS
Data were obtained before (Phase I, April-September 2014) and after (Phase II, January-April 2015) the release of the AUC document from six participating pediatric cardiology centers. Site investigators determined the indication for TTE and assigned appropriateness rating based on the AUC document: Appropriate (A), May Be Appropriate (M), Rarely Appropriate (R), or "unclassifiable" (U) if it did not fit any scenario in the AUC document.


RESULTS
Of the total 4562 TTEs, 310 (6.8%) were performed for syncope: 174/2655 (6.6%) Phase I and 136/1907 (7.1%) Phase II, P=.44. Overall, 168 (50.5%) were for indications rated A, 63 (18.9%) for M, 79 (23.7%) for R, and 23 (6.9%) for U. Release of AUC did not change the appropriateness of TTEs [A=51.6% vs 49.0%, P=.63, R=20.2% vs 28.3%, P=.09]. Overall syncope-related R indications formed 15.7% of R indications for all the echocardiograms performed in the entire Pediatric Appropriate Use (PAUSE) study (11.9% Phase I and 22.4% Phase II, P=.002). TTEs were normal in majority of the patients except 7 that had incidental findings.


CONCLUSIONS
In conclusion, syncope is a common reason for indications rated R and release of the AUC document did not improve appropriate utilization of TTE in syncope. Targeted educational interventions are needed to reduce unnecessary TTEs in children with syncope.
Emory University School of Medicine, Atlanta, GA, USA.
Heather M
http://orcid.org/0000-0003-0945-0203
HM
Phelps
Emory University School of Medicine, Atlanta, GA, USA.
Michael S
MS
Kelleman
Emory University School of Medicine, Atlanta, GA, USA.
Courtney E
CE
McCracken
Massachusetts General Hospital, Boston, MA, USA.
Oscar J
OJ
Benavidez
Emory University School of Medicine, Atlanta, GA, USA.
Robert M
RM
Campbell
Duke University, Durham, NC, USA.
Pamela S
PS
Douglas
Mayo Clinic Rochester, Rochester, MN, USA.
Benjamin W
BW
Eidem
Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA.
Wyman W
WW
Lai
Nicklaus Children's Hospital, Miami, FL, USA.
Leo
L
Lopez
Children's Hospital at Montefiore, Bronx, NY, USA.
Kenan W D
KW
Stern
Nicklaus Children's Hospital, Miami, FL, USA.
Elizabeth
E
Welch
Emory University School of Medicine, Atlanta, GA, USA.
Ritu
R
Sachdeva
D000293:Adolescent; D002648:Child; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010045:Outpatients; D010372:Pediatrics / Q000379:methods*; D011446:Prospective Studies; D013575:Syncope / Q000175:diagnosis*
appropriate use; congenital heart defects; congenital heart disease; syncope; transthoracic echocardiography