Elsevier

The Journal of Pediatrics

Volume 184, May 2017, Pages 137-142
The Journal of Pediatrics

Original Articles
Appropriateness of Outpatient Echocardiograms Ordered by Pediatric Cardiologists or Other Clinicians

https://doi.org/10.1016/j.jpeds.2017.01.073Get rights and content

Objective

To assess the appropriateness and diagnostic yield of TTEs ordered by various pediatric providers according to the pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) before its release.

Study design

Clinic notes of patients aged ≤18 years who underwent initial outpatient TTE between April and September 2014 were reviewed to determine the AUC indication, and appropriateness was assigned based on the AUC document. Ordering physicians were categorized into cardiologists, primary care physicians (PCPs; including pediatricians and family practitioners [FPs]), and noncardiology subspecialists.

Results

Of the 1921 TTEs ordered during the study period, 84.6% were by cardiologists, 9.2% by pediatricians, 3.4% by FPs, and 2.8% by noncardiology subspecialists. The appropriateness rate for cardiologists was higher than that for PCPs (86% vs 64%; P < .001) but not noncardiology subspecialist (86% vs 87%; P = .80). PCPs had a significantly higher proportion of studies that could not be classified compared with cardiologists (35% vs 5%; P < .001) and noncardiology subspecialists (35% vs 11%; P < .001), owing primarily to a lack of adequate clinical information. The likelihood of an abnormal finding was higher in TTEs ordered by a cardiologist vs those ordered by a noncardiologist (OR, 4.8; 95% CI, 2.1-10.9; P < .001).

Conclusions

Compared with PCPs, cardiologists ordered more TTEs, had the highest yield of abnormal findings, and had greater appropriateness of TTE orders. A large proportion of TTEs ordered by PCPs were unclassifiable owing to insufficient information. This study lays a framework for provider education and improvement in the TTE order intake process.

Section snippets

Methods

We reviewed medical records of patients aged <18 years who underwent initial outpatient TTE at our center during a 6-month period (April 1, 2014, to September 30, 2014) before publication of the pediatric AUC document. All patients seen by the pediatric cardiologists had a clinic encounter associated with the order and details of the clinical indication readily available. These patients were included in the previously published AUC implementation study.6 The noncardiology providers were either

Results

The 1921 initial outpatient TTE evaluations performed during the study period included 1625 (84.8%) ordered by cardiologists, 176 (9.2%) ordered by pediatricians, 66 (3.4%) ordered by FPs, and 54 (2.8%) ordered by noncardiology subspecialists. These orders were from 38 different cardiologists, 127 pediatricians, 51 FPs, and 18 noncardiology subspecialists. These subspecialists included otolaryngologists (n = 3), pediatric surgeons (n = 3), endocrinologists (n = 2), gastroenterologists (n = 2),

Discussion

This study reports the differences in appropriateness of TTEs ordered by pediatric cardiologists and noncardiologists based on the pediatric AUC. The ordering pattern of physicians in this study was not influenced by the AUC document, because the data were collected from a period before publication of the document. This study shows that at our center, PCPs and noncardiology subspecialists order fewer TTEs than cardiologists. The cardiologists had a significantly higher proportion of studies

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The authors declare no conflicts of interest.

Portions of this study were presented as an abstract during the Cardiology Section of the American Academy meeting, Washington, DC, October 24-27, 2015.

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