Objective The educational intervention (EI) through the Pediatric Appropriate Use of Echocardiography (PAUSE) multicenter study resulted in improved appropriateness of transthoracic echocardiogram (TTE) orders at our center. The current study evaluated if this pattern persisted after cessation of EI and the potential physician characteristics influencing appropriateness. Design Outpatients (≤18 years old) seen for initial evaluation during the EI (July to October, 2015) and 6‐month post‐EI (May to August, 2016) phases were included. Comparison was made between TTE rates and appropriateness ratings during EI and post‐EI phase. Association between TTE rate and appropriateness with physician characteristics (age, experience, patient volume, and area of practice) was determined using odds ratio. Results The study included 7781 patients (EI: N = 4016; post‐EI: N = 3765) seen by 31 physicians. Comparison of appropriateness ratings in a randomized sample (EI: N = 1270; post‐EI: N = 1325 patients) showed no significant differences between the two phases (appropriate: 75.2% vs 74.9%, P = .960; rarely appropriate 4.1% vs 6.5%, P = .065). Though there was significant variability among physicians for TTE order appropriateness (P = .044) and ordering rate (P <.001), none of their characteristics were associated with appropriateness and only a higher patient volume was associated with decreased odds of TTE ordering (OR =0.7). Conclusion The PAUSE study EI resulted in maintaining appropriate utilization of TTEs at our center for 6 months following its cessation. Though not statistically significant, there was a trend toward increase in the proportion of studies for indications designated rarely appropriate (R). There was significant physician variability in TTE ordering and appropriateness during both phases. Development of EI to reduce physician variability and integration of EI with provider workflow may help sustain appropriate TTE utilization.

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Introduction:In the pediatric Appropriate Use Criteria (AUC), abnormal electrocardiogram (ECG) in an asymptomatic patient has been rated as an "Appropriate" indication for transthoracic echocardiogram (TTE). We hypothesized that the yield of abnormal findings on TTE for this indication will be low.Methods: All asymptomatic patients (≤ 18 years) from January 1, 2015 to December 31, 2017 who underwent initial outpatient evaluation at our center and had a TTE ordered for an abnormal ECG, were included. Clinic records were reviewed to obtain ECG and TTE findings.Results: Of the 199 study patients, 13 (6.5%) had abnormal findings. Incomplete right bundle branch block (IRBBB) had the highest yield of abnormal TTE findings (7/28), with secundum atrial septal defect being the most common (5/7); (Odds ratio (OR) compared to other ECG findings 9.2, 95% CI (2.8-29.9), P < .001). OR further increased to 14.6, 95% CI (3.1-68.0), P < .001 when either IRBBB, right axis deviation, or right ventricular hypertrophy were present. Left ventricular hypertrophy on ECG had only one incidental abnormality on TTE, while ST segment changes, left axis deviation, right/left atrial enlargement, premature atrial/ventricular contractions, ectopic atrial rhythm, sinus bradycardia/pause, preexcitation, low-grade atrioventricular block, and junctional rhythm did not yield abnormal TTEs. Conclusions:The yield of abnormal findings on TTE when performed for the AUC indication for an abnormal ECG in asymptomatic pediatric patients is low except when performed for ECG abnormalities suggestive of right heart disease such as IRBBB, right axis deviation, or right ventricular hypertrophy. Future revisions of the AUC document could consider further stratification of this indication and corresponding appropriateness ratings based on ECG findings rather than combining into one broad category. K E Y W O R D Sappropriate, criteria, asymptomatic, electrocardiogram | 231 DASGUPTA et al.