Clinical Utility of Guideline-Based Echocardiography: A Prospective Study of Outpatient Referral Patterns at a Tertiary Care Center

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Background

The spread of echocardiography has increased the number of requests for echocardiography and the length of patient waiting lists in National Health Systems. This overuse of echocardiography may also result in a decrease in examination quality because of an excess in workload. The recommended use of guidelines for the requesting of echocardiograms could reduce the demand for this investigation and thus reduce both workload and health care costs.

Methods

In a prospective study of 520 outpatients in a large tertiary referral center, we analyzed adherence by family physicians and cardiovascular specialists to published guidelines for requesting echocardiograms; the use of a written indication justifying the request for the first and subsequent examinations; the diagnostic outcome; and the clinical utility of each echocardiogram performed.

Results

Most echocardiograms (72%) were requested by specialists, follow-ups were frequent (72%), and 14% of these proved normal. Among first examinations, 49% of those requested by family physicians and 36% of those requested by specialists were normal (P = not significant [NS]); in both groups 27% of the requests lacked a written indication. Family physicians requested echocardiograms chiefly for arterial hypertension, palpitations, chest pain, and valve disease, whereas specialists most often requested echocardiograms for checking valve prostheses, ischemic heart disease, and valve disease. The rate of adherence to guidelines (54% vs 52%, P = NS) and clinical utility (60% vs 61%, P = NS) was low and similar for family physicians and specialists. Provision of a written indication for the examination by the requesting physician correlated strongly to the clinical utility of the test (P < .001), and adherence of indication to guidelines was the major determinant of clinical utility at logistic regression analysis (P < .001).

Conclusion

The rate of adherence to guidelines was lower than desirable and similar for family physicians and cardiovascular specialists. Adherence to guidelines and provision of a written specific indication strongly enhanced the value of the echocardiographic investigation.

Section snippets

Echocardiographic Examination and Study Protocol

The study was performed at the Centro Cardiologico Monzino, IRCCS, a teaching hospital in the Milan area of Northern Italy. Outpatient echocardiography for adults is performed by cardiologists on rotation in 2 laboratories, each with 2 (morning and afternoon) work shifts. We prospectively analyzed 520 outpatient echocardiograms scanned consecutively by a single cardiologist during a 7-month period (January to July 2004), evenly distributed over the working week, who used a Philips Sonos 2000

Indications for Requesting Echocardiograms, Diagnosis, and Demographics

Of the 520 echocardiograms analyzed (male patients, 53.7%; female patients, 46.3%; P = not significant [NS]), 148 were first examinations and 372 were follow-up studies (28.5% vs 71.5%, P < .001). Urgent examinations were in a minority (5.2%) and were not analyzed separately. Indications were undetermined in 20 patients (3.8%). When hospital specialists were compared with family physicians, the majority of requests originated from the former (374, 72% vs 146, 28%: P < .001) (Table 1), and this

Discussion

Our prospective study is the first to analyze echocardiography requesting patterns for outpatients at a tertiary referral center. It found a rather low, generally 50%, adherence of indications to guidelines and a 60% utility of the examination, after referral by either family physicians or hospital specialists, but with differences between cardiovascular subspecialists. Adherence of indications to guidelines was significantly associated with the clinical utility of the examination.

Study Limitations

A diagnostic test may have an incremental value with respect to the information known about the patient. Some of this information may have not been disclosed to the patient by the physician ordering the examination, included on the request form, or apparent from the medical documentation available to researchers. This may have led to underestimation of both adherence to indication guidelines and the clinical utility of the echocardiogram. Further, the evaluation of the clinical utility of an

Conclusions

Our results suggest that, within the NHS, the increasing referrals to specialists do not reduce unnecessary echocardiograms because adherence of indications to guidelines and clinical utility of the examinations were similar between specialists and family physicians. Patient waiting lists and health care costs may be favorably influenced by implementing policies aimed at increasing knowledge and application of existing indication guidelines. By reducing unnecessary examinations, these policies

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