Clinical Investigation
Pediatric Echocardiography
Temporal Trends in Utilization of Transthoracic Echocardiography for Common Outpatient Pediatric Cardiology Diagnoses over the Past 15 Years

https://doi.org/10.1016/j.echo.2016.12.008Get rights and content

Background

No data exist regarding the temporal trends in utilization of transthoracic echocardiography (TTE) in an outpatient pediatric cardiology setting. This study evaluates the trends in utilization of TTE for common diagnoses known to have low diagnostic yield and the factors influencing these trends.

Methods

Patients evaluated at our pediatric cardiology clinics from January 2000 to December 2014 and discharged with final diagnoses of innocent murmur, noncardiac chest pain, benign syncope, and palpitations were included. Variables collected retrospectively included patient age, sex, insurance type, distance from clinic, and ordering physician's years of experience since fellowship.

Results

Of the 74,881 patients seen by 35 physicians, 36,053 (48.1%) had a TTE. The TTE rates increased from the beginning of 2000 to the end of 2004 (5.2% per year; P < .001) and then steadily declined until the end of 2014 (1.6% per year; P < .001). Utilization for noncardiac chest pain remained the highest, and use in infants increased significantly during the study period (P < .001). After adjusting for all other factors, the following variables were associated with higher TTE utilization: younger age, males, Medicaid insurance, increased distance from clinic, and being seen by less experienced physicians. Temporal trends persisted after adjusting for all these factors.

Conclusions

After an initial surge in TTE utilization from 2000 to 2004, there was a steady decline. This study identifies some important factors influencing these trends. This information could help design quality interventions, but additional factors need to be explored since the trends persist despite adjusting for these factors.

Section snippets

Methods

This retrospective study was approved by the Institutional Review Board of Children's Healthcare of Atlanta. Patients ≤18 years old who underwent initial evaluation in an outpatient setting at our pediatric cardiology clinics from January 2000 to December 2014 and were discharged with a final diagnosis of innocent murmur, noncardiac chest pain, benign (vasovagal or neurocardiogenic) syncope, and palpitations were included. This information was obtained from a database maintained by our billing

Results

During the study period 78,787 patients were seen by 50 physicians and discharged with a final diagnosis of innocent murmur, noncardiac chest pain, benign syncope, or palpitations. Fifteen physicians and 3,906 patients seen by these physicians were excluded since they saw fewer than 500 patients during the study period. Of the remaining 74,881 subjects who were analyzed, 36,053 (48.1%) had a TTE. In the randomly selected sample of 100 patients, the final discharge diagnosis matched with that

Discussion

This is the first pediatric study describing temporal trends in utilization of TTE for common outpatient diagnoses for which such testing is known to be low yield. We noted that following the initial growth in the rate of TTE use from 2000 to 2004, there has been a steady decline. This study also identifies some important factors that influenced TTE utilization over the 15-year study period. Interestingly, despite adjusting for these factors, the temporal trends in TTE utilization persisted.

Conclusions

In this large single-center study focused on four common final discharge diagnoses, there was an upward trend in the TTE rate from 2000 until 2004, which was followed by a steady decline over the past decade. Although the initial growth mirrored changes in adult cardiology, the decline in the latter part of the study is in sharp contrast to the trends reported in adult patients, where there remains continued growth in these services. While some important factors influencing the temporal trends

Acknowledgments

We acknowledge the help provided by Meron Kebede, Sibley Heart Canter Cardiology, for data extraction. We also acknowledge the Emory + Children's Pediatric Biostatistics Core for their help with analysis of the data.

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      One such study showed that underutilization of echocardiography among critically ill adult inpatients was associated with poorer outcomes.10 Resource utilization is also affected by wide variability in clinical practice not only among centers but also among providers within each center.4,17-20 For noncardiac imaging among pediatric patients, the American College of Radiology has 17 appropriateness criteria documents that include guidelines for multimodality imaging use in the evaluation of common clinical scenarios such as appendicitis, walking with a limp, and sinusitis.21

    • Factors Influencing Pediatric Outpatient Transthoracic Echocardiography Utilization Before Appropriate Use Criteria Release: A Multicenter Study

      2017, Journal of the American Society of Echocardiography
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      Previous investigations have focused on appropriateness ratings of ordered TTE but did not include data on TTE that was not ordered, or they focused on a single indication.8,12,13 A recent single-center review reported temporal trends in TTE utilization for common benign discharge diagnoses and factors associated with utilization but did not determine AUC indications.10 In our study, 12% of visits with an indication of either appropriate or rarely appropriate were discordant with TTE ordering.

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