Do Appropriate Use Criteria for TTE Improve Clinical Impact?

"The study results are very provocative and it's great that people are starting to look at this important question", said Athena Poppas, MD, FACC.

A new study  published in JAMA: Internal Medicine raises questions about the role of appropriate use criteria (AUC) in actively changing clinical care when it comes to transthoracic echocardiography (TTE).

While the study, which looked at 535 consecutive TTEs performed at a single medical center, found a high percentage (91.8 percent) of the TTEs performed to be appropriate based on the ACC's 2011 AUC for Echocardiography,   fewer than one in three TTEs produced an active change in care, and more than one in five TTEs resulted in no change in care.


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"Inappropriate AUCs should be associated with a lower prevalence of an active change in care and a higher prevalence of no change than appropriate TTEs," the study authors noted. "However, in our study, we found no difference in the prevalence of an active change or no change in care for appropriate vs. inappropriate TTEs. These data suggest that AUC for TTE have not fulfilled one of its anticipated results, 'to have a significant impact on physician decision-making,' and they did not curb the growth of TTE use since publication." Given the increased focus on controlling rising health care costs and ongoing discussions around responsible use of limited medical resources, the study authors offer several recommendations for improving the clinical impact of TTE, in addition to AUC, including:

  • Development of better metrics for identifying patients or scenarios when TTE is likely to result in no change in care
  • Future research focused on understanding the role of diagnostic testing in patient-centered care
  • Closer looks at alternative, less expensive treatment options with similar benefits to TTE
  • Inclusion of "necessity" into the AUC development and rating process

The authors also suggest that participation in educational programs like "Choosing Wisely," of which the ACC is a part, could assist in raising awareness among both clinicians and patients about "the cost and utility of testing in daily care." In all of these cases, the authors note that collaboration among hospitals, administrators, politicians, economists, the government and patients will be key.

In an editorial comment, William Armstrong, MD, FACC, and Kim A. Eagle, MD, MACC, note that the " AUC are under a constant state of iteration and investigation; clearly, the 2011 revision addresses many of the shortcomings of the earlier versions. Certainly, the AUC are not without remaining flaws and ideally should result in a categorization scheme that can be demonstrated to have a consistent, but not necessarily invariable, effect on medical decision making." They add that moving forward, the retrospective study points the way for further prospective studies looking at the impact of echocardiography and how it affects physician decision making.

Keywords: Prevalence, Health Resources, Health Care Costs, Awareness, Echocardiography, Patient-Centered Care

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