Indications, utility and appropriateness of echocardiography in outpatient cardiology

Abstract

Objective:Respect of “appropriateness” is considered an essential requirement, both on the clinical and the economic profile, and also as it helps to shorten the waiting list. However, only a few studies have dealt with the control of appropriateness in clinical practice, and most of them have focused only on hospital admissions and invasive procedures.Materials and Methods:INDICARD-out is a prospective, multicenter study carried out by A.R.C.A. (Associazioni Regionali Cardiologi Ambulatoriali) cardiologists from 13 Italian Regions, providing information on indications, utility and appropriateness of echocardiography in outpatient cardiology.Results:A total of 2110 prescriptions for echocardiogram were evaluated. Hypertension (23%) and the screening of asymptomatic subjects (17%) by far were the most frequent indications to echocardiography. Overall, 54% of the tests resulted appropriate, 30% were of uncertain appropriateness and 16% were inappropriate. Besides, 31% of the echocardiograms were not useful, and 28% were non pertinent for patient management. The vast majority of prescriptions (72%) came from non-cardiologist physicians (54% from general practitioners). The echocardiograms prescribed by cardiologists were significantly more appropriate, more useful and more pertinent than the tests prescribed by non-cardiologists.Conclusions:The appropriateness, utility and pertinence of the echocardiography are still suboptimal in practice cardiology, especially when indicated by non-cardiologists. The cardiologist, from mere executor of tests prescribed and managed by other physicians, should gain the role of the clinician who takes care of all the cardiologic needs of the patient community.

Frequency and Determinants of Inappropriate Use of Treadmill Stress Test for Coronary Artery Disease

“…Although we discovered excessive inappropriate ETT from the public healthcare system, inappropriate diagnostic workup was significantly higher from the private healthcare setup. Hypertension was the most common comorbidity among the appropriate ETT referrals, and this outcome was in line with that described in an Italian study by Orsini et al [ 17 ]. The multivariate models demonstrated that only being from a private health setup was an independent predictor of the inappropriate use of ETT.…”

Impact of incorporating echocardiographic screening into a clinical prediction model to optimise utilisation of echocardiography in primary care

“…Considering the training and clinical backgrounds, data from over 2800 echo prescriptions in Italy showed better guideline‐driven appropriateness in prescriptions made by experts (cardiologists), resulting in more frequent derivation of useful information (63.1% cardiologist vs 46% non‐cardiologist) and consequently more abnormal findings (74.3% vs 55%) 21 . In another analysis including 2110 patients with mean 60.4 years old, to whom echo was mainly prescribed because of hypertension (22%) and screening (16.8%), cardiology training was also associated with higher rates of class I indication, usefulness and pathological features 22 . Thus, it is anticipated that standard echocardiograms ordered by the primary care staff in Brazil—with heterogeneous training background—will likely have suboptimal pretest evaluation, limiting their utility.…”

“…21 In another analysis including 2110 patients with mean 60.4 years old, to whom echo was mainly prescribed because of hypertension (22%) and screening (16.8%), cardiology training was also associated with higher rates of class I indication, usefulness and pathological features. 22 Thus, it is anticipated that standard echocardiograms ordered by the primary care staff in Brazil-with heterogeneous training background-will likely have suboptimal pretest evaluation, limiting their utility. This, in addition to the uneven distribution of health resources and test availability in the Brazilian territory (even inside the same state) and to financial crisis, contribute to the current growing waiting lists.…”

“…Echocardiography (echo) remains one of the most used imaging modalities in clinical practice, providing incremental information with low risk to the patient through ultrasound technology. 1,2 The availability of portable and affordable machines has allowed echo to go beyond the frontiers of specialised centres, and its indications have progressively increased. 3,4 In response to marked increases in utilisation, the delay in its access in places where machines are scarce is inevitable.…”

Combinação de Ferramentas de Telecardiologia para Estratificação de Risco Cardiovascular na Atenção Primária: Dados do Estudo PROVAR+

“…Graças ao desenvolvimento da tecnologia, a ecocardiografia tem se tornado progressivamente portátil e acessível, passando dos centros de imagem para os locais de atendimento, com potencial para chegar a ambientes não atendidos. 3,4 Portanto, uma abordagem em duas etapas, que inclui a realização do ecocardiograma por não especialistas, seguida de interpretação remota por cardiologistas credenciados, é uma estratégia de rastreamento promissora. 5,6 Isso pode permitir uma alocação de recursos mais eficaz e a implementação de programas de rastreamento mais amplos, permitindo um diagnóstico mais precoce e um tratamento imediato, especialmente onde os recursos são escassos.…”