Ruchi Kapoor, MD, PhD DSR 2 Cost Consciousness Project A penny for an echo? Ruchi Kapoor, MD, PhD DSR 2 Cost Consciousness Project

Overheard in the halls of UCI… “Indication for an echo? They have a heart.”

129 patient records reviewed 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 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) Match indication to one of the 202 indications in the 2011 Guidelines for appropriate use criteria of echocardiography (Tables 1 – 7) Determine the appropriate use criteria rating for each echocardiogram performed

Results Who is ordering…? Internal Medicine 41 CCU 21 Neurology 18 Family Medicine 11 MICU 8 Hem/Onc 4 CT surgery 3 OB/Gyn HBS Neurosurgery 2 Colorectal 2 ED Gen Surgery Trauma Vascular Burn 1 GI Surgery Ortho Transplant Urology

Results Of the 129 echocardiograms… Raw numbers Percent Appropriate 117 91% Uncertain 3 2% Inappropriate 9 7%

Results Service Indication AUC? OB/Gyn Appropriate Use Criteria (AUC): U – Uncertain I – Inappropriate Service Indication AUC? OB/Gyn Routine surveillance (>1y) of HF when there is no change in clinical status or cardiac exam U Team B Re-evaluation of known HF with a change in clinical status or cardiac exam with a clear precipitating change in medication or diet Team C “ Neurology Intracranial hemorrhage I Burn Transient bacteremia with a documented nonendovascular source of infection Gen surgery Routine surveillance (<3 y) of mild valvular stenosis without a change in clinical status or cardiac exam Team A Initial evaluation [of murmur] when there are no other symptoms or signs of valvular or structural heart disease Family Medicine Suspected pulmonary embolism in order to establish diagnosis Team D Asymptomatic isolated sinus bradycardia Neurosurgery Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease

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 Definition of appropriate use: 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. “