Kerley Robert N, O'Flynn Siun
School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland.
Ir J Med Sci. 2019 Feb;188(1):89-99. doi: 10.1007/s11845-018-1843-9. Epub 2018 Jun 18.
The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. Very few studies have assessed how medical centers overseas perform against AUC. Evidence is now emerging that inappropriate referral rates in Europe are similar to those reported in the US.
This study systematically reviewed published evidence to identify (1) whether the 2011 AUC are applicable to medical centers outside the US (2) the level of adherence to the AUC across multiple centers, (3) the main factors which cause deviation from AUC, (4) any changes in referral rates since the publication of AUC, and (5) any factors and/or intervention strategies which promote adherence to AUC.
Electronic databases were systematically searched for papers related to AUC and cardiac imaging. Following screening and application of eligibility criteria, data was extracted from ten reports involving 8561 TTE studies. Classification rates were 99.5 and 98% for US studies and studies outside the US respectively. Overall, 7119 TTE studies were classified as appropriate (83.1%) of which 3724 were US referrals (84.7%) and 3395 originated outside the US (81.5%). Six of the included studies independently observed significantly more appropriate referrals among inpatients compared to outpatients (p < 0.001). US centers observed no significant difference in appropriate referral rates between physician specialties while one UK study showed cardiac surgeons ordered inappropriate TTEs more frequently than other specialties (p < 0.05). This review found no obvious trend in appropriate referral rates between 2012 and 2015 indicating no temporal change in physician ordering patterns. Only one educational interventional study met the author's criteria which showed that while intervention was effective during its implantation (26% reduction in TTEs ordered per day), TTE referral rates regressed to pre-intervention levels overtime.
In conclusion, the American guideline AUC are applicable to centers outside the US and their implementation across five international centers suggest almost 1 in 5 scans could be avoided.
美国超声心动图学会（ASE）制定了2011年适用标准（AUC），旨在为转诊医生提供指导，以应对人们对不必要的经胸超声心动图（TTE）检查申请日益增长的担忧。很少有研究评估海外医疗中心在遵循AUC方面的表现。现在有证据表明，欧洲不适当转诊率与美国报告的类似。
本研究系统回顾已发表的证据，以确定（1）2011年AUC是否适用于美国以外的医疗中心；（2）多个中心对AUC的遵循程度；（3）导致偏离AUC的主要因素；（4）自AUC发布以来转诊率的任何变化；（5）促进遵循AUC的任何因素和/或干预策略。
系统检索电子数据库中与AUC和心脏成像相关的论文。在筛选并应用纳入标准后，从涉及8561项TTE研究的10份报告中提取数据。美国研究和美国以外研究的分类率分别为99.5%和98%。总体而言，7119项TTE研究被分类为适当（83.1%），其中3724项是美国的转诊（84.7%），3395项来自美国以外（81.5%）。纳入的六项研究独立观察到，与门诊患者相比，住院患者中适当转诊显著更多（p<0.001）。美国中心观察到不同医生专业之间的适当转诊率无显著差异，而一项英国研究表明，心脏外科医生开出不适当TTE检查的频率高于其他专业（p<0.05）。本综述发现2012年至2015年期间适当转诊率没有明显趋势，表明医生开单模式没有随时间变化。只有一项教育干预研究符合作者的标准，该研究表明，虽然干预在实施期间有效（每天开出的TTE检查减少26%），但TTE转诊率随时间推移又回到了干预前水平。
总之，美国指南AUC适用于美国以外的中心，其在五个国际中心的实施表明，近五分之一的扫描检查可以避免。
