Perspective:

The AUC for echocardiography were developed as a guideline for identification of clinical scenarios in which an echocardiogram would be appropriate and likely to assist in diagnosis or alter clinical management, or inappropriate, in which case little or no change in a specific diagnosis or patient management would be expected. Multiple surveillance studies have demonstrated rates of inappropriate TTE of 10% to 15% depending on practice situations. In this study, the authors described a fairly simple and straightforward educational initiative directed at house staff on an inpatient academic general medicine teaching service consisting of lectures, pocket cards, and feedback regarding ordering patterns. They then compared the rate of inappropriate and appropriate TTE to a prior 10-month period on the same inpatient service, although obviously with different teams of physicians. At first glance, there was an immediate impact on ordering patterns with a significant reduction in the rate of inappropriate TTEs being ordered, which would be a commendable result, and likely to result in reduced inappropriate expenditures. As a side evaluation, the authors also evaluated 50 patients with congestive heart failure during each time period and determined that there was no difference in the rate of appropriate and inappropriate TTE for the 50 patients, suggesting that their intervention was not reducing utilization in appropriate settings. While the intervention in all likelihood was responsible for a substantial reduction in the inappropriate TTE ordering rate, other factors clearly are at play. First, the study period in 2012 occurred after publication of multiple manuscripts on AUC and heightened awareness of appropriate and inappropriate medical utilization both in the medical literature and often in the lay press. As such, the house staff and medical teams under evaluation in 2012 may have already been more well educated regarding appropriate utilization of medical resources than their colleagues were in 2011. Additionally, the number of admissions per day fell from 16.8 in the preintervention period to 13.9 in the intervention period, suggesting the possibility of a shift in either patient acuity or an enhanced pattern of ‘appropriate’ admissions versus more marginal indications for hospital admission. This would have the effect of providing the house staff with a larger proportion of patients appropriately admitted for whom TTE may be an appropriate tool compared to the preintervention period, which may have represented a different patient population. As such, while the intervention described here is commendable for its straight-forward nature and simplicity, which renders it applicable to virtually any institution, it may be only part of the story with respect to improved rates of inappropriate and appropriate TTE.