Appropriate Use and Clinical Impact of Transthoracic Echocardiography

Study Questions:

What proportion of transthoracic echocardiograms (TTEs) affect clinical care in an academic medical center, both overall and in appropriate use criteria (AUC) “appropriate” and “inappropriate” subgroups?


A retrospective review of medical records was performed from 535 consecutive TTEs at an academic medical center. TTEs were classified according to 2011 AUC by two cardiologists blinded to clinical impact, and were assessed for clinical impact by two cardiologists blinded to AUC designation. Clinical impact was assigned to one of the following three categories: 1) active change in care, 2) continuation of current care, or 3) no change in care.


Overall, 31.8% of TTEs resulted in an active change in care, 46.9% in continuation of current care, and 21.3% in no change in care. By 2011 AUC, 91.8%of TTEs were appropriate, 4.3% were inappropriate, and 3.9% were uncertain. There was no statistically significant difference detected between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs. 21.7%, p = 0.29).


Although nine in ten TTEs were appropriate by 2011 AUC, fewer than one in three TTEs resulted in an active change in care, nearly one half resulted in continuation of current care, and slightly more than one in five resulted in no change in care. The authors concluded that the low rate of active change in care (31.8%) after TTEs that was mostly classified as appropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently, while providing high-quality care.


TTE is a widely available and versatile tool that accounts for almost one half of all cardiac imaging services. AUC for echocardiography were developed to improve patient care and health outcomes. Although prior studies have shown that most TTEs are appropriate by AUC, this study tests whether ‘appropriate,’ ‘uncertain,’ or ‘inappropriate’ TTEs appeared to have different effects on patient management. The negative finding could have been due to flawed AUC, or to a relatively small sample size underpowered to detect a difference. The finding of a low ratio of active change in care based on TTE results (or of continuation of care directly attributable to TTE results) could be due to (as the authors suggest) overuse of TTE. An alternative conclusion is that there is a limited ability to retrospectively assess the clinical impact of TTE, in whole or in part due to absence of documentation in the medical record.

Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Patient Care, Trichothecenes, Documentation, Medical Records, Echocardiography

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