Evaluation of Appropriate Use of Preoperative Echocardiography before Major Abdominal Surgery: A Retrospective Cohort Study

Background Preoperative resting echocardiography is often performed before noncardiac surgery, but indications for preoperative resting echocardiography are limited. This study aimed to investigate appropriateness of preoperative resting echocardiography using the Appropriate Use Criteria for Echocardiography, which encompass indications from the guidelines on perioperative cardiovascular evaluation and management and nonperioperative indications independent of the perioperative period. The authors hypothesized that patients are frequently tested without an appropriate indication. Methods Records of patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent a major abdominal surgery from 2005 to 2017 were included. These databases contain de-identified records of health services for more than 250 million patients with primary or Medicare supplemental health insurance coverage through employer-based fee-for-service, point-of-service, or capitated plans. Patients were classified based on the presence of an outpatient claim for resting transthoracic echocardiography within 60 days of surgery. Appropriateness was determined via International Classification of Diseases, Ninth Revision –Clinical Modification, and International Classification of Diseases, Tenth Revision–Clinical Modification principal and secondary diagnosis codes associated with the claims, and classified as “appropriate,” “rarely appropriate,” or “unclassifiable” using the Appropriate Use Criteria for Echocardiography. Results Among 230,535 patients in the authors’ cohort, preoperative resting transthoracic echocardiography was performed in 6.0% (13,936) of patients. There were 12,638 (91%) studies classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Among the classifiable studies, 8,959 (71%) were deemed “appropriate,” while 3,679 (29%) were deemed “rarely appropriate.” Surveillance of chronic ischemic heart disease and uncomplicated hypertension accounted for 43% (1,588 of 3,679) of “rarely appropriate” echocardiograms. Conclusions More than one in four preoperative resting echocardiograms were considered “rarely appropriate” according to the Appropriate Use Criteria for Echocardiography. A narrow set of patient characteristics accounts for a large proportion of “rarely appropriate” preoperative resting echocardiograms. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

2011 appropriate use criteria audit of an echocardiography lab in South Western Nigeria

Cardiovascular diseases are the major cause of death worldwide. Since its discovery in the 20th century, Echocardiography (ECHO) has become one of the pivotal tools in assessing cardiac structure and function. With the increase in requests for ECHO, there has risen an unwanted problem - inappropriate requests for ECHO. There has therefore arisen the need to audit ECHO labs for the appropriateness of ECHO requests. The patients referred from the outpatient clinics and in-patient wards for ECHO from June 1st, 2015 till September 30th, 2016 were recruited. Their request form data, clinical information, and ECHO results were analyzed as appropriate. The 2011 appropriate use criteria for Transthoracic ECHO was utilized. The most common indication out of the 2174 ECHOs reviewed was hypertension (16%), closely followed by hypertensive heart disease (12.4%). The percentage of appropriate, inappropriate, and uncertain indications according to the 2011 appropriate use criteria (AUC) for transthoracic echocardiography were 41.4%, 31.1%, and 0.1% respectively. Less than ten percent (9.3%) of the indications could not be classified by the 2011 AUC while 18.1% of the ECHOs had no indication. When indications of Hypertension, Hypertensive Heart Disease (HHD) and heart failure were compared, heart failure was significantly associated with eccentric Left Ventricular Hypertrophy (LVH), larger LV mass, lower BMI, larger cardiac dimensions, reduced ejection fraction, lower trans mitral A velocities than the other two indications. Concentric LVH was showed a trend towards being most in those with HHD (p= 0.072). The percentage of appropriate indications was low in this study as compared to others, largely because of large inappropriate indications. There is a need to ensure appropriate indications are filled for ECHO request forms. The 2011 AUC may need to be reviewed to expand the appropriate group of indications.