Why the study?
The relationship between the ordering frequency of rarely appropriate transthoracic echocardiograms, healthcare utilization, and patient outcomes in coronary artery disease was not known.
Does care by a cardiologist with high rates of low-value echocardiogram ordering affect healthcare utilization and clinical outcomes in patients with CAD?
Cohort (n=3,966)
Yes
Does care by a cardiologist with high rates of low-value echocardiogram ordering affect healthcare utilization and clinical outcomes in patients with CAD?
Cardiologists who frequently order low-value echocardiograms are less likely to prescribe evidence-based medications or screening tests, which is associated with higher 1-year all-cause mortality in CAD patients.
Answers are grounded in this paper and cite their sources.
High low-value TTE ordering may flag lower high-value care in CAD; leaves open whether it affects outcomes or warrants intervention.
BACKGROUND: The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. METHODS AND RESULTS: A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar. CONCLUSIONS: Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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Tharmaratnam et al. (2019) conducted a cohort in Coronary artery disease (n=3,966). High ordering frequency of rarely appropriate transthoracic echocardiograms vs. Low ordering frequency of rarely appropriate transthoracic echocardiograms was evaluated on All-cause mortality at 1 year (OR 1.54, 95% CI 1.04-2.28).
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