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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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.

10. 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. “