Transthoracic echocardiography (TTE) is one of the most-commonly used tests in clinical cardiology. It is a widely available, cost effective, and non-invasive test that can provide substantial and valuable data regarding initial diagnosis, management decisions, evaluation of cardiac status, and clinical follow-up of patients. Moreover, echocardiography may be performed on an elective basis or in an emergency setting.
The University of the Philippines – Philippine General Hospital (UP-PGH) is the national university hospital and the largest tertiary care medical center with a 1500-bed capacity, providing diverse and subspecialized medical and surgical services, both in the inpatient and outpatient settings. Being a national university hospital and referral center, the services of PGH are mainly directed to the underserved strata of the population. In 2013, the hospital attended to almost 600 hundred thousand service patients. Of these, almost 98% are classified as indigent or those heavily relying on the hospital’s resources for their medical care. [1] Hence, there is a need to rationalize the resources and redirect them to those patients who truly need them.
The Division of Cardiovascular Medicine of the Department of Medicine operates the adult echocardiography laboratory of the hospital. The lab provides ultrasound-based examinations such as the transthoracic echocardiography (TTE), trans-esophageal echocardiography (TEE), stress and contrast echocardiography and vascular duplex studies. These ultrasound-based examination procedures comprised 89% of all diagnostic procedures done in the year 2016. The resting transthoracic 2d-echo comprised 94% of the diagnostics done at the PGH Section of Cardiology echocardiography lab in 2016. [2] There has been an average of 5.8% increase in the utilization of TTE per year since 2014. In the year 2017, the echocardiography lab accommodated 6,295 patients, which is 6.4% higher than last year. [2]
In light of its multiple and diverse uses, the appropriate use criteria (AUC) in echocardiography are essential to improve clinical outcomes while preserving hospital and patient resources. Clinically, the application of AUC avoids potential over-indications; from a socio-economic perspective, AUC prevents unnecessary health expenses in institutions with a relatively restricted health care budget such. [3]
The latest AUC of echocardiography were published in 2011 by the American College of Cardiology Foundation, the Appropriate Use Criteria Task Force, and the American Society of Echocardiography (AUC 2011). [4] The AUC 2011 considered 202 indications, 98 of which for transthoracic 2d-echo, and designated each indication as appropriate use (median 7–9), uncertain use (median 4–6), and inappropriate use (median 1–3). [4] The PGH Section of Cardiology also released its own Clinical Echocardiography Appropriate Use Criteria for TTE based mainly on AUC 2011 [5]. Apart from these guidelines, there seem to be no other published studies focusing on the clinical value of appropriate use criteria in transthoracic 2d-echocardiography at the local front. Through this study, we intend to evaluate the appropriateness of transthoracic echocardiograms in a high-volume tertiary medical center using established appropriate use criteria.
The UP-PGH, as the premier tertiary referral hospital, aims to render quality health care by serving as a role model in healthcare delivery systems and leading the medical community in undertaking health systems researches. The resting transthoracic 2d-echo comprises 94% of the diagnostic procedures performed at the PGH Section of Cardiology echocardiography lab [4]. In international studies on cardiac imaging utilization, with the first implementation of the AUC in 2007, there was a decline in the volume of cardiac imaging yearly from 2009 to 2013 [6]. The application of the AUC 2011 among hospitals in the US, UK and Australia have shown that their echocardiographic requests are 80–90% appropriate and that 1–2 out of 10 requests can be avoided. [7–10] The correction in the utilization of echocardiographic procedures decongested the volume of imaging in the lab and improved the utilization of hospital resources [6–10]. This study, however, is not intended to decrease the volume of procedures at the lab. Historical records of the hospital clearly show a steady rise in the demand for echo. This, in fact, will be further augmented by creating a greater awareness of clear indications for echocardiography, allowing the laboratory to serve a greater segment of the population. More importantly, the AUC will refine cardiac imaging by redirecting its use towards scenarios where it may facilitate cost effective optimal care.
Comparison between the appropriateness of echocardiography between regional and national hospitals are not that different. In a study by Bailey et.al, [11] they found that the adherence to the AUC 2011 regarding inpatients in a regional hospital was consistent with that encountered in university hospitals. The application also of the AUC in the community setting was fairly comparable in an Italian study in 2012 by Ballo et.al., the adherence in the AUC 2011 in a community setting was only appropriate for 80% of the studies. [12]
In addition, the results of this study may be used for the improvement of the healthcare delivery system of the hospital specifically in terms of cardiac diagnostics. It may help create a quality improvement project (QIP) regarding TTE indications which includes regular lectures for medical staff on AUC 2011, placement of visual aids summarizing AUC 2011 in the echo lab, and performance of monthly auditing by cardiology fellows in the echo lab.