Salik Jonathan R, Sen Sounok, Picard Michael H, Weiner Rory B, Dudzinski David M
Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.
Echocardiography. 2019 Apr;36(4):631-638. doi: 10.1111/echo.14314.
Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU.
Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator.
Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101).
Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.
合理使用标准（AUC）是促进医疗资源合理利用的一项重要机制。迄今为止，尚无研究评估当前的AUC对在心脏重症监护病房（CICU）进行的经胸超声心动图（TTE）的适用性。我们分析了一家四级医疗学术医学中心的CICU连续两年进行的TTE检查情况，推测当前的AUC可能无法充分描述TTE在现代CICU中的作用。
两名研究人员根据2011年的AUC对TTE的适应证进行独立分类。如果研究人员无法为某一特定检查指定AUC分类，则将其视为无法分类。研究人员之间的分歧通过协商解决。无法达成共识的病例由第三名研究人员进行最终裁决。
在826例TTE检查中，619例被分类为合适（74.9%，置信区间71.8%-77.9%），12例为不确定（1.5%，置信区间0.75%-2.5%），21例为很少合适（2.5%，置信区间1.6%-3.9%），174例无法分类（21.1%，置信区间18.3%-24.0%）。最常见的无法分类的适应证是“不明病因心脏骤停后心脏结构或功能的初始评估”（n = 101）。
当前TTE的AUC可能无法充分应对CICU中遇到的临床病例的复杂性。在我们对826例连续TTE检查的研究中，21.1%无法分类，这反映了在这种独特临床环境中应用AUC的困难。因此，需要进一步研究以更好地界定在CICU进行TTE检查的合适性。
