Clinical application of the first pediatric appropriate use criteria (AUC) for transthoracic echocardiography (TTE) is feasible and found most pediatric TTE to be appropriate, according to a study published Aug. 31 in the Journal of the American College of Cardiology.

As the first pediatric AUC for TTE was recently released, Ritu Sachdeva, MBBS, FACC, from the Emory University School of Medicine and Children’s Healthcare of Atlanta Sibley Heart Center Cardiology in Atlanta, and colleagues sought to determine the clinical applicability of the AUC in pediatric cardiology clinics. They examined 2,655 initial outpatient TTE evaluations ordered by 102 physicians at six centers. The median age of patients was ten years. Data were collected from April to September 2014, prior to the release of the AUC document and, therefore, physicians were unaware of the AUC ratings. Reasons for each TTE were rated as appropriate, may be appropriate, and rarely appropriate based on the document. The primary outcome measure for the study was the number of TTEs ordered for rarely appropriate indications.

Of the total study population, 1,876 (71 percent) of studies were appropriate, 316 (12 percent) were rated may be appropriate and 319 (12 percent) were rarely appropriate. The final 144 (5 percent) studies were unclassifiable as the reason for the TTE was not included in the AUC document. The three most common indications for TTEs rated appropriate were pathologic murmur, exertional chest pain and abnormal ECG without symptoms. For the rates deemed may be appropriate, the most common reasons were positive family history of congenital left-sided heart lesion; chest pain with other symptoms or signs of cardiovascular disease, a benign family history and a normal ECG; and unexplained pre-syncope. The most common rarely appropriate indications were presumptively innocent murmur; syncope with no other symptoms or signs of cardiovascular disease, a benign family history and a normal ECG; and palpitations with no other symptoms of signs of cardiovascular disease, a benign family history, and a normal ECG.

Overall, 85 percent of TTEs were normal. Of the top three TTE appropriate indications, pathologic murmur had the highest yield of abnormal findings and exertional chest pain had the lowest. The majority of abnormal findings for TTEs done for appropriate indications were related to the indication, while only one of seven abnormal finding deemed rarely appropriate was related. The authors also found that most common indication for TTE in children <10 years of age was a murmur (innocent or pathologic), whereas chest pain was the most common indication for those ≥10 years of age. Children with abnormal findings were much younger than those with normal findings.

Lastly, the authors identified gaps in the document to address in future revisions. Under the current AUC, 5 percent of studies were unclassifiable. The authors note that two noteworthy scenarios forming a large portion of the unclassifiable studies were a family history in a member other than a first-degree relative and the ausculatory finding of a click. They also identified 24 unused indications which may be consolidated in future revisions.

Sachdeva et al. conclude that the findings of this study show that educational interventions may reduce the use of TTE for rarely appropriate indications. Moving forward, future studies should evaluate the change in patient care and outcomes as a result of the AUC.

In an editorial comment accompanying the study, Carolyn A. Altman, MD, FACC, recognizes the AUC for TTE as an important first step and lays out eight steps for improving the AUC in the future.  Her recommendations include: (1) reassurance to the pediatric cardiology community that the AUC should supplement clinical judgment, not supersede it; (2) improve and broaden applicability of future versions of the AUC; (3) incorporate results of AUC assessments into future documents; (4) consider cost and efficiency for various indications; (5) develop educational programs and tools to improve knowledge of AUC; (6) develop electronic tools to track appropriateness of TTS orders; (7) asses preauthorization and reimbursement over time for pediatric TTE; and (8) evaluate the true impact of AUC on patient care and outcomes. 

Keywords: Cardiovascular Diseases, Chest Pain, Echocardiography, Electrocardiography, Equidae, Heart Murmurs, Outcome Assessment, Health Care, Outpatients, Patient Care, Syncope

< Back to Listings