Evaluation of Appropriate Use of Preoperative Echocardiography Before Major Abdominal Surgery

A Retrospective Cohort Study

Allyson Tank, M.D.; Robert Hughey, M.D.; R. Parker Ward, M.D.; Peter Nagele, M.D., M.Sc.; Daniel S. Rubin, M.D., M.S.

Disclosures

Anesthesiology. 2021;135(5):854-863. 

In This Article

Abstract and Introduction

Abstract

Background: Preoperative resting echocardiography is often performed before noncardiac surgery, but indications for preoperative resting echocardiography are limited. This study aimed to investigate appropriateness of preoperative resting echocardiography using the Appropriate Use Criteria for Echocardiography, which encompass indications from the guidelines on perioperative cardiovascular evaluation and management and nonperioperative indications independent of the perioperative period. The authors hypothesized that patients are frequently tested without an appropriate indication.

Methods: Records of patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent a major abdominal surgery from 2005 to 2017 were included. These databases contain de-identified records of health services for more than 250 million patients with primary or Medicare supplemental health insurance coverage through employer-based fee-for-service, point-of-service, or capitated plans. Patients were classified based on the presence of an outpatient claim for resting transthoracic echocardiography within 60 days of surgery. Appropriateness was determined via International Classification of Diseases, Ninth Revision–Clinical Modification, and International Classification of Diseases, Tenth Revision–Clinical Modification principal and secondary diagnosis codes associated with the claims, and classified as "appropriate," "rarely appropriate," or "unclassifiable" using the Appropriate Use Criteria for Echocardiography.

Results: Among 230,535 patients in the authors' cohort, preoperative resting transthoracic echocardiography was performed in 6.0% (13,936) of patients. There were 12,638 (91%) studies classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Among the classifiable studies, 8,959 (71%) were deemed "appropriate," while 3,679 (29%) were deemed "rarely appropriate." Surveillance of chronic ischemic heart disease and uncomplicated hypertension accounted for 43% (1,588 of 3,679) of "rarely appropriate" echocardiograms.

Conclusions: More than one in four preoperative resting echocardiograms were considered "rarely appropriate" according to the Appropriate Use Criteria for Echocardiography. A narrow set of patient characteristics accounts for a large proportion of "rarely appropriate" preoperative resting echocardiograms.

Introduction

Preoperative echocardiography is often performed before major noncardiac surgery in an effort to improve perioperative care, as major adverse cardiac events complicate 1 in 33 hospitalizations for noncardiac surgery.[1] The American College of Cardiology (Washington, D.C.) and the American Heart Association (Dallas, Texas) practice guidelines for perioperative cardiovascular evaluation for noncardiac surgery recommend preoperative resting transthoracic echocardiography for a narrow set of cardiac conditions that directly impact perioperative care, such as suspected valvular heart disease or left ventricular dysfunction.[2] A key tenet of the perioperative guidelines is that preoperative cardiovascular testing should be reserved for clinical scenarios that would warrant testing independent of upcoming surgery. Thus, to accurately assess the appropriateness of preoperative resting echocardiography, a broad understanding of all reasonable indications for resting echocardiography outside the perioperative setting is required.

The American College of Cardiology Foundation established Appropriate Use Criteria for Echocardiography in response to marked increases in the utilization of cardiac imaging.[3] The 2011 Appropriate Use Criteria for Echocardiography outlined common clinical scenarios and designated them, using the recommended updated nomenclature, as "appropriate," "may be appropriate," or "rarely appropriate."[4,5] While the Appropriate Use Criteria for Echocardiography overlap with the preoperative cardiovascular guidelines, they provide a more comprehensive scope of indications for echocardiography independent of the perioperative period. Previous population-based studies have evaluated preoperative echocardiography utilization before noncardiac surgery and its impact on postoperative outcomes. These studies did not identify an association between preoperative resting echocardiography and improved 30-day mortality or major adverse cardiac events, even in high-risk patients.[6,7] However, there has been no large-scale effort to assess the use of resting echocardiography in the context of the appropriate use criteria. This information is particularly important as we approach the implementation of Centers for Medicare and Medicaid Services (Baltimore, Maryland) Appropriate Use Criteria Program in 2022, which will require providers to demonstrate adherence to appropriate use criteria when ordering advanced imaging studies.[8] We therefore determined the appropriateness of preoperative echocardiography by applying the Appropriate Use Criteria for Echocardiography in a population-based study.

The current study utilizes the Truven Health MarketScan Commercial and Medicare Supplemental Databases (Truven Health Analytics, USA) to investigate the frequency of preoperative resting echocardiography for major abdominal procedures from 2005 to 2017 and to assess the appropriateness of these tests according to the Appropriate Use Criteria for Echocardiography. We hypothesize that patients are frequently tested for indications deemed unnecessary by the Appropriate Use Criteria for Echocardiography.

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