Key result
EMR-integrated appropriate use criteria linked to ~8-point drop in rarely appropriate pediatric echocardiograms.
Why the study?
Before integration of pediatric appropriate use criteria (AUC) for initial transthoracic echocardiography (TTE) in outpatients with palpitations and arrhythmias, a high proportion of rarely appropriate TTEs were ordered.
Observational (n=463)
No
Absolute Event Rate: 8.8% vs 17.2%
Absolute Risk Reduction: 8.4%
p-value: p=0.005
May support EMR-embedded AUC to reduce inappropriate pediatric echocardiograms; hypothesis-generating, should not yet change practice.
Before the integration of the pediatric appropriate use criteria (AUC) for initial transthoracic echocardiography (TTE) in the outpatient setting with our electronic medical record (EMR), there was a high proportion of "rarely appropriate" TTEs (17.2%) ordered for palpitations/arrhythmias. We studied appropriateness ratings and applicability of pediatric AUC on the initial outpatient evaluation of children with palpitations/arrhythmias after EMR integration and the yield of abnormal TTEs for these indications. METHODS: We obtained data after the EMR integration of the AUC at our institution. The TTE ordering physician assigned the AUC indication and the corresponding appropriateness ratings autopopulated as: appropriate (A), may be appropriate (M), and rarely appropriate (R). We recorded the abnormal TTE findings. RESULTS: A total of 463 TTEs were ordered for palpitations/arrhythmias. Overall, 142 (30.7%) were for A, 263 (56.8%) for M, 41 (8.8%) for R, and 17 (3.7%) for "unclassifiable" indications. Only 14 (3.0%) had abnormal TTE findings, of which none were for indications rated R. A TTE ordered for premature ventricular contractions in a 17-year-old revealed a significant abnormality (moderate atrial septal defect). CONCLUSIONS: The integration of AUC with the EMR significantly improved the appropriate utilization of TTE for palpitations and arrhythmias with a decrease in the proportion of TTEs for R indications (17.2%-8.8%). Although the yield of abnormal findings on TTE performed for palpitations/arrhythmias is quite low, the AUC ratings successfully stratified the indication with no abnormalities for indications rated R. These findings can guide future revisions of AUC indications and ratings to optimize resource utilization.
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Dasgupta et al. (2020) conducted an observational in Palpitations and arrhythmias in pediatric patients (n=463). Integration of appropriate use criteria (AUC) into the electronic medical record (EMR) vs. Pre-EMR integration phase (historical control) was evaluated on Proportion of TTEs ordered for indications rated Rarely Appropriate (R) on the initial outpatient evaluation (p=0.005). Integration of echocardiography appropriate use criteria into the electronic medical record reduced the proportion of rarely appropriate echocardiograms ordered for pediatric palpitations and arrhythmias from 17.2% to 8.8%.
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