New Appropriateness Criteria Aim to Minimize Echo Misuse

Reed Miller

March 31, 2011

March 31, 2011 (Washington, DC) — The authors of new expanded appropriate-use criteria (AUC) for echocardiography hope the development and application of comprehensive AUC by physicians and payers will allow echocardiography to escape the fate of other imaging modalities that are now subject to onerous preauthorization rules and review by radiology benefits managers [1].

The chair of the 2011 appropriate-use criteria for echocardiography writing committee, Dr Pamela Douglas (Duke University, Durham, NC), told heartwire that "echo is the last one of the imaging tests that is not being required to have prior certification or authorization. It's almost like the horse is out of the barn for nuclear tests because we've had to do 'preauthorization' for that for years."

For example, the American College of Cardiology (ACC), which spearheaded the AUC effort along with the American Society of Echocardiography (ASE) and several other major societies, is currently working with insurance companies in Delaware to use the AUC to determine coverage for echocardiography instead of contracting a third-party benefits-management company to preauthorize tests. "So [we're saying to payers] before you do it to echo, consider this other route," she said.

The question of just what percentage of echocardiograms are medically warranted is garnering increasing attention, most recently on, where a blog post by editor-in-chief Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA) has sparked a lively debate. A 2007 study at the Massachusetts General Hospital coauthored by Dr Michael Picard (Massachusetts General Hospital, Boston), a member of the AUC writing group, found that about 13% of the transthoracic echo tests ordered at that center during a 35-day study period were classified as either inappropriate or of uncertain value by the AUC [2]. The most common inappropriate use was suspicion of endocarditis. Other studies in academic centers, community hospitals, and veterans' hospitals show the rate of inappropriate or uncertain echos usually ranges from 10 to 15%. "I would like that number to be smaller--5% or lower. There's always going to be some number of inappropriate echos, but we can do a better job," Picard told heartwire .

Douglas also cited a recent study by Dr Bimal Shah (Duke University, Durham, NC), which found that more than one-half of all revascularization patients in community practice had at least one stress echo test within 24 months of revascularization, but that only 5% of patients tested ultimately required repeat revascularization and that the timing of the tests clustered around natural "anniversaries" like six or 12 months [3]. "So [many of the tests] seemed to be ordered for surveillance and not symptoms, and yet the appropriateness criteria focus on symptoms," Douglas said.

Despite these studies, there is currently no comprehensive echocardiography registry that can more precisely measure the rate of inappropriate testing or reveal geographic practice patterns with echocardiography, Douglas said. "Those data are pretty hard to come by because the appropriate-use criteria are specifically written for clinical scenarios--whether somebody is low, medium, or high risk and symptomatic or not--and that kind of information is not generally in claims data, and there are no imaging registries right now," Douglas said. "I think it would be great [if there were imaging registries, because] if we're really going to improve care, we have to measure, benchmark, and understand what the gaps are, and that is hard to do without effective data."

New Criteria Cover Many More Clinical Scenarios

The ACC/ASE published AUC on transthoracic and transesophageal echocardiography covering 59 indications in June 2007 and then published AUC specifically for stress echocardiography covering 51 indications in March 2008.

The new 2011 AUC, the first to address both rest and stress echocardiography in the same document, cover 202 indications, including more detailed information on echocardiography for valvular heart disease, perioperative evaluations, thoracic aortic disease, and pulmonary hypertension, Douglas pointed out. In the new AUC, 97 indications are rated as appropriate, 34 are rated as uncertain, and 71 are rated as inappropriate.

"There are so many uses for echo that it's hard to develop something that includes all of the scenarios," Picard said. "So that first document covered a lot of the most common scenarios but not all of them . . . but the goal of the newest document was to fill in all of the gaps and be as comprehensive as possible. We learned that there were a few ambiguities in the first document, so we tried to clarify those issues."

Picard added, "One of the nice things about AUC documents is that they really help to show where the evidence is lacking for the use of these imaging technologies, and it really puts the burden on the cardiology community to go out and collect the data to really see if it's appropriate or not to use echocardiography or another imaging modality."

Douglas pointed out that in addition to collaborations with payers like the one in Delaware, the ACC is promoting the echocardiography AUC as part of its FOCUS national quality-improvement initiative, an online learning community for practices to assess their own appropriateness and track it against benchmarks. Also, the Intersocietal Accreditation Commission that accredits echo labs is encouraging them to use the AUC to track their own performance, she noted.

Picard reports that he has a research relationship with Edwards Lifesciences. Disclosures for the other contributors to the new AUC are listed in the document.