ACC 2015: Appropriate use criteria make first appearance in pediatric community

March 14, 2015 – The ACC has launched a collaboration with several partners to develop AUC for outpatient pediatric echocardiography.

pamela-douglas-newsAs cardiovascular imaging technologies have improved, their use has increased—leading to a need for ensuring that the technology is being used in the most effective manner. Appropriate use criteria (AUC) for echocardiography of adult patients have been in use for almost a decade.

“We had a lot of growth in testing and procedures without a clear understanding of the need for those; there were no standard benchmarks,” said Pamela Douglas, MD, Ursula Geller Professor of Research in Cardiovascular Diseases at Duke and a DCRI faculty member. “AUC were created so that there would be an expert-driven consensus for the use of imaging and procedures in clinical practice.”

Until recently, however, nothing similar existed for imaging or procedures for pediatric patients. To address that need, the American College of Cardiology has collaborated with several partners to develop AUC for the initial use of outpatient pediatric echocardiography.

“There was a feeling on the part of the pediatrics community that there’s a potential to have an overuse of initial TTEs [transthoracic echocardiograms] in an outpatient cardiac setting,” said Douglas. “Establishing pediatric AUC is an important quality improvement effort aimed at making sure that patient care is as effective as possible by providing some benchmarks, a standard practitioners can reference.”

The pediatric echocardiography AUC cover 113 indications based on a variety of clinical scenarios. A 15-member panel of experts rated each of these indications as “appropriate,” “may be appropriate,” or “rarely appropriate.” As a second step, to determine the applicability of the AUC in clinical practice, data were collected from 2,668 echocardiography studies and 80 physicians among six participating sites (Emory University School of Medicine, Children’s Hospital at Montefiore, Miami Children’s Hospital, Massachusetts General Hospital, Mayo Clinic Rochester, and New York-Presbyterian Morgan Stanley Children’s Hospital).

Of the 2,668 studies, only 145 were unclassifiable (5.4 percent).

“This tells us that the guidelines are very comprehensive,” said Douglas. “Furthermore, the ‘rarely appropriate’ rate was a little lower than 5 percent, so we’re very pleased with that.” Unused indications were also examined; of the 113 indications, 24 were not used. “That could mean there is room to streamline things a bit,” Douglas said.

Now that the pediatric AUC exist and have been shown to work well in defining current practice, covering a vast majority of the most common indications, Douglas says that physicians and patients should use them to assist in decision making. When asked what the next steps are now that the initial AUC have been developed, Douglas indicated that a closer look should be given to the specific findings within each of the appropriateness categories. Among the questions to consider are: Are we finding more pathology in the appropriate indications? Are we finding any pathology in the rarely appropriate ones? How often would strict adherence to the AUC cause a clinician to miss an important finding? Can we modify the AUC to better capture the need for an echocardiogram?

“We are planning a follow-up study involving provider education to determine if knowledge of AUC changes care, and if those changes improve quality of care,” said Douglas.