Author + information
- Received April 29, 2015
- Revision received June 16, 2015
- Accepted June 22, 2015
- Published online September 8, 2015.
- Ritu Sachdeva, MBBS∗∗ (, )
- Joseph Allen, MA†,
- Oscar J. Benavidez, MD‡,
- Robert M. Campbell, MD∗,
- Pamela S. Douglas, MD§,
- Benjamin W. Eidem, MD‖,
- Lara Gold, MA†,
- Michael S. Kelleman, MS, MSPH∗,
- Leo Lopez, MD¶,
- Courtney E. McCracken, PhD∗,
- Kenan W.D. Stern, MD#,
- Rory B. Weiner, MD‡,
- Elizabeth Welch, MD¶ and
- Wyman W. Lai, MD, MPH∗∗
- ∗Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia
- †American College of Cardiology, Washington, DC
- ‡Massachusetts General Hospital, Boston, Massachusetts
- §Duke University, Durham, North Carolina
- ‖Mayo Clinic, Rochester, Minnesota
- ¶Miami Children’s Hospital, Miami, Florida
- #Children’s Hospital at Montefiore, New York, New York
- ∗∗Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Ritu Sachdeva, Emory University School of Medicine, Children’s Healthcare of Atlanta, 1405 Clifton Road, Atlanta, Georgia 30322.
Background Recently published appropriate use criteria (AUC) for initial pediatric outpatient transthoracic echocardiography (TTE) have not yet been evaluated for clinical applicability.
Objectives 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.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 29, 2015.
- Revision received June 16, 2015.
- Accepted June 22, 2015.
- American College of Cardiology Foundation