How I do it: judging appropriateness for TTE and TEE

Abstract

The increasing cost of healthcare is a widespread international problem to which the cost of imaging has been an important contributor. Some imaging tests are ordered inappropriately and contribute to wasted use of resources. Appropriate use criteria have been developed in the USA in order to guide test selection, but there are a number of problems, including the evidence base for these criteria and the steps that can be taken to change physician practice. A restrictive approach to test ordering is difficult to fit to the nuances of clinical presentation and may compromise patient care. We propose an alternative approach to physician guidance based on the most common markers of inappropriate testing.

Figure 1

Differences in the use of echocardiography in the US in 1996. Regional variations by hospital referral region, expressed as a ratio to the US average. From Wennberg D, et al. The Dartmouth Atlas of Cardiovascular Health Care. P65. 1999 [11].

Figure 2

Major causes of inappropriate echocardiography. Proportions of inappropriate tests (x axis) ordered by cardiologists (red) and non-cardiologists (blue). Modified from Ward RP et al. [39].

Figure 3

Proposed checklist to discriminate possible inappropriate orders. A simplified check-list to be reviewed at point of service, as a prompt to seeking clarification from the referring physician.