Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
J Am Soc Echocardiogr. 2017 Dec;30(12):1214-1224. doi: 10.1016/j.echo.2017.08.014. Epub 2017 Nov 1.
The first pediatric appropriate use criteria (AUC) address the use of initial transthoracic echocardiography in outpatients by all ordering providers. The aim of this study was to appraise the performance of the AUC across pediatric cardiologists, noncardiologist subspecialists, and primary care providers (PCPs). A further aim was to describe the variations in ordering patterns of different groups of practitioners, which could serve as the basis for targeted quality improvement activities.
Electronic health records for Seattle Children's Hospital and its four regional sites were retrospectively reviewed for initial transthoracic echocardiographic studies performed on patients aged ≤18 years. A sample of 1,000 consecutive studies and a sample of 1,514 studies in which studies ordered by noncardiologists were enriched were reviewed. The ordering provider type, study indication, and findings (normal, incidental, or abnormal) were classified. Indications mapped to three categories: appropriate (A), may be appropriate (M), and rarely appropriate (R). If multiple indications were documented, the highest level of appropriateness was used.
In the consecutive sample, pediatric cardiologists ordered 81%, noncardiologist subspecialists 13%, and PCPs 5% of the total studies. In the enriched sample, only 4% were unclassifiable by the AUC. Abnormal findings were identified in 23% of A, 13% of M, and 9% of R studies (P = .03). Appropriateness varied among the three groups of providers (P < .001). For pediatric cardiologists, 67% of studies were indication category A, 13% M, and 14% R. Noncardiologist subspecialists ordered the highest percentage of A studies (88%) and the lowest percentage of R studies (1%). PCPs had the highest percentage of R indications (18%), and 23% could not be fully classified, because of insufficient order information. Yield of abnormal findings was highest for subspecialists (23%), intermediate for cardiologists (19%), and lowest for PCPs (15%; P = .03).
The AUC performed well across all provider types, as measured by the low percentage of unclassifiable indications and the observed relationship between greater appropriateness and higher yield of abnormal findings. The three provider types differed in appropriateness rates and had distinct ordering patterns, which could form the basis for future targeted quality improvement efforts.
首批儿科适宜性使用标准（AUC）针对的是所有开单医生在门诊中对初始经胸超声心动图的使用。本研究的目的是评估 AUC 在儿科心脏病专家、非心脏病专科医生和初级保健提供者（PCP）中的表现。另一个目的是描述不同群体医生的开单模式差异，这可以作为有针对性的质量改进活动的基础。
回顾性查阅西雅图儿童医院及其四个区域站点的电子病历，以获取对年龄≤18 岁患者进行的初始经胸超声心动图研究。我们回顾了 1000 例连续研究和 1514 例非心脏病医生开单丰富的研究样本。对开单医生类型、研究指征和结果（正常、偶发或异常）进行了分类。指征被分为三类：适宜（A）、可能适宜（M）和不适宜（R）。如果记录了多个指征，则采用最高适宜性级别。
在连续样本中，儿科心脏病专家开单占总数的 81%，非心脏病专科医生开单占 13%，PCP 开单占 5%。在丰富样本中，只有 4%的超声不能被 AUC 分类。在 A 类研究中，23%的研究发现异常，在 M 类研究中为 13%，在 R 类研究中为 9%（P=0.03）。三个医生群体的适宜性差异有统计学意义（P<0.001）。对于儿科心脏病专家，67%的研究属于 A 类指征，13%的属于 M 类，14%的属于 R 类。非心脏病专科医生开单的 A 类研究比例最高（88%），R 类研究比例最低（1%）。PCP 的 R 类指征比例最高（18%），23%的研究无法完全分类，因为订单信息不足。亚专科医生的异常发现阳性率最高（23%），心脏病专家次之（19%），PCP 最低（15%；P=0.03）。
AUC 在所有医生类型中的表现都很好，这体现在可分类的指征比例低，以及更大的适宜性与更高的异常发现阳性率之间的关系。这三种医生类型在适宜性比率上存在差异，且具有不同的开单模式，这可以作为未来有针对性的质量改进努力的基础。
