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Ruchi Kapoor, MD, PhD DSR 2 Cost Consciousness Project Overheard in the halls of UCI… “Indication for an echo? They have a heart.” Methods 141 inpatient transthoracic echocardiograms done at UCI between March 1 – 14, 2015 could not find 7 patients in the EMR 5 were repeat TTEs on the same patient 129 patient records reviewed Methods 1. Determine indication Indication recorded on the order Review progress notes from the admission (primarily finding the part of the A&P that mentions why the TTE was ordered) 2. Match indication to one of the 202 indications in the 2011 Guidelines for appropriate use criteria of echocardiography (Tables 1 – 7) 3. Determine the appropriate use criteria rating for each echocardiogram performed Results Who is ordering…? Internal Medicine 41 Colorectal 2 CCU 21 ED 2 Neurology 18 Gen Surgery 2 Family Medicine 11 Trauma 2 MICU 8 Vascular 2 Hem/Onc 4 Burn 1 CT surgery 3 GI Surgery 1 OB/Gyn 3 Ortho 1 HBS 3 Transplant 1 Neurosurgery 2 Urology 1 Results Of the 129 echocardiograms… Raw numbers Percent 117 91% Uncertain 3 2% Inappropriate 9 7% Appropriate Results Service OB/Gyn Team B Indication Burn Gen surgery Team A Family Medicine Team A Team C AUC? Routine surveillance (>1y) of HF when there is no change in clinical status U or cardiac exam Re-evaluation of known HF with a change in clinical status or cardiac U exam with a clear precipitating change in medication or diet Team C Neurology Appropriate Use Criteria (AUC): U – Uncertain I – Inappropriate “ Intracranial hemorrhage U I Transient bacteremia with a documented nonendovascular source of I infection Routine surveillance (<3 y) of mild valvular stenosis without a change in I clinical status or cardiac exam Initial evaluation [of murmur] when there are no other symptoms or signs I of valvular or structural heart disease “ Suspected pulmonary embolism in order to establish diagnosis “ I I I Team D Asymptomatic isolated sinus bradycardia I Neurosurgery Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease I Conclusions Medicine services (Internal and Family), cardiology service and neurology (primarily for stroke evaluations) are the main utilizers of inpatient TTEs. Of 129 TTEs, <10% did not meet appropriate use criteria (about ~340 TTEs/year). Most of the uncertain/inappropriate TTEs were ordered when there was no change in clinical status or when patient history offered alternative diagnosis. Medicine was the biggest offender when it came to ordering inappropriately, though all departments were culprit to some extent. Reference ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography J Am Soc Echocardiogr 2011;24:229-67 Definition of appropriate use: “An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequence by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication. “