Download Use of TTE in the Inpatient Setting

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. “