Rose-Felker Kirsten, Kelleman Michael S, Campbell Robert M, Sachdeva Ritu
Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA.
Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
J Pediatr. 2017 May;184:137-142. doi: 10.1016/j.jpeds.2017.01.073. Epub 2017 Feb 24.
To assess the appropriateness and diagnostic yield of TTEs ordered by various pediatric providers according to the pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) before its release.
Clinic notes of patients aged ≤18 years who underwent initial outpatient TTE between April and September 2014 were reviewed to determine the AUC indication, and appropriateness was assigned based on the AUC document. Ordering physicians were categorized into cardiologists, primary care physicians (PCPs; including pediatricians and family practitioners [FPs]), and noncardiology subspecialists.
Of the 1921 TTEs ordered during the study period, 84.6% were by cardiologists, 9.2% by pediatricians, 3.4% by FPs, and 2.8% by noncardiology subspecialists. The appropriateness rate for cardiologists was higher than that for PCPs (86% vs 64%; P < .001) but not noncardiology subspecialist (86% vs 87%; P = .80). PCPs had a significantly higher proportion of studies that could not be classified compared with cardiologists (35% vs 5%; P < .001) and noncardiology subspecialists (35% vs 11%; P < .001), owing primarily to a lack of adequate clinical information. The likelihood of an abnormal finding was higher in TTEs ordered by a cardiologist vs those ordered by a noncardiologist (OR, 4.8; 95% CI, 2.1-10.9; P < .001).
Compared with PCPs, cardiologists ordered more TTEs, had the highest yield of abnormal findings, and had greater appropriateness of TTE orders. A large proportion of TTEs ordered by PCPs were unclassifiable owing to insufficient information. This study lays a framework for provider education and improvement in the TTE order intake process.
在门诊经胸超声心动图（TTE）的儿科适当使用标准（AUC）发布之前，根据该标准评估不同儿科医疗服务提供者所开具的TTE检查的合理性及诊断率。
回顾了2014年4月至9月期间接受首次门诊TTE检查的18岁及以下患者的临床记录，以确定AUC指征，并根据AUC文件确定其合理性。开具检查单的医生分为心脏病专家、初级保健医生（PCP，包括儿科医生和家庭医生[FP]）以及非心脏病专科医生。
在研究期间开具的1921份TTE检查单中，84.6%由心脏病专家开具，9.2%由儿科医生开具，3.4%由家庭医生开具，2.8%由非心脏病专科医生开具。心脏病专家的检查单合理性率高于初级保健医生（86%对64%；P＜0.001），但与非心脏病专科医生相比无差异（86%对87%；P = 0.80）。与心脏病专家（35%对5%；P＜0.001）和非心脏病专科医生（35%对11%；P＜0.001）相比，初级保健医生开具的无法分类的检查单比例显著更高，主要原因是缺乏足够的临床信息。心脏病专家开具的TTE检查发现异常的可能性高于非心脏病专家开具的检查（OR，4.8；95%CI，2.1 - 10.9；P＜0.001）。
与初级保健医生相比，心脏病专家开具的TTE检查更多，异常发现率最高，且TTE检查单的合理性更高。由于信息不足，初级保健医生开具的大部分TTE检查单无法分类。本研究为医疗服务提供者的教育以及TTE检查单接收流程的改进奠定了框架。
