How I Do It: Judging Appropriateness for TTE and TEE
If the strategy of laboratory-based audit is selected, a simple screening process is required for the thousands of requests which are submitted to the laboratory every year. Our approach has been to base this around the indications which generate the greatest numbers of inappropriate tests in the 2011 AUC for echocardiography (TTE and TEE, but not including stress, Figure 2). These are related to routine surveillance, evaluation of symptoms without other symptoms/signs of cardiac disease and low pretest probability of endocarditis. Other situations include a suspicion of pulmonary embolism, when the exam would not change management, and when a test is ordered by non-cardiologists.
(Enlarge Image)
Figure 2.
Major causes of inappropriate echocardiography. Proportions of inappropriate tests (x axis) ordered by cardiologists (red) and non-cardiologists (blue). Modified from Ward RP et al. [39].
Routine surveillance is the most common inappropriate indication for TTE. The most common situations of inappropriate repeat imaging of ventricular function include assessment in patients with known CAD and no change in clinical status or cardiac exam, systemic hypertension without symptoms or signs of hypertensive heart disease, and within a year of previous testing in heart failure (systolic or diastolic) when there is no change in clinical status or cardiac exam). A very common situation in patients with nonspecific symptoms includes patients with lightheadedness/presyncope without other symptoms). Common valve-related indications include <3 year after prosthetic valve implantation in the absence of known or suspected valve dysfunction, and evaluation of infective endocarditis when there is transient fever without evidence of bacteremia or new murmur or transient bacteraemia with a pathogen not typically associated with endocarditis. For transoesophageal echocardiography, the most common inappropriate indications are related to endocarditis with low pretest probability and routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all concerns. The availability of this information on the characteristics of inappropriate tests has enabled the development of a checklist to identify studies where a discussion regarding the merits of testing can be initiated from the laboratory (Figure 3).
(Enlarge Image)
Figure 3.
Proposed checklist to discriminate possible inappropriate orders. A simplified check-list to be reviewed at point of service, as a prompt to seeking clarification from the referring physician.
Screening Imaging Requests for Appropriateness
If the strategy of laboratory-based audit is selected, a simple screening process is required for the thousands of requests which are submitted to the laboratory every year. Our approach has been to base this around the indications which generate the greatest numbers of inappropriate tests in the 2011 AUC for echocardiography (TTE and TEE, but not including stress, Figure 2). These are related to routine surveillance, evaluation of symptoms without other symptoms/signs of cardiac disease and low pretest probability of endocarditis. Other situations include a suspicion of pulmonary embolism, when the exam would not change management, and when a test is ordered by non-cardiologists.
(Enlarge Image)
Figure 2.
Major causes of inappropriate echocardiography. Proportions of inappropriate tests (x axis) ordered by cardiologists (red) and non-cardiologists (blue). Modified from Ward RP et al. [39].
Routine surveillance is the most common inappropriate indication for TTE. The most common situations of inappropriate repeat imaging of ventricular function include assessment in patients with known CAD and no change in clinical status or cardiac exam, systemic hypertension without symptoms or signs of hypertensive heart disease, and within a year of previous testing in heart failure (systolic or diastolic) when there is no change in clinical status or cardiac exam). A very common situation in patients with nonspecific symptoms includes patients with lightheadedness/presyncope without other symptoms). Common valve-related indications include <3 year after prosthetic valve implantation in the absence of known or suspected valve dysfunction, and evaluation of infective endocarditis when there is transient fever without evidence of bacteremia or new murmur or transient bacteraemia with a pathogen not typically associated with endocarditis. For transoesophageal echocardiography, the most common inappropriate indications are related to endocarditis with low pretest probability and routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all concerns. The availability of this information on the characteristics of inappropriate tests has enabled the development of a checklist to identify studies where a discussion regarding the merits of testing can be initiated from the laboratory (Figure 3).
(Enlarge Image)
Figure 3.
Proposed checklist to discriminate possible inappropriate orders. A simplified check-list to be reviewed at point of service, as a prompt to seeking clarification from the referring physician.
Source...