Comparison of the 2007 and 2011 appropriate use criteria for transthoracic echocardiography in various clinical settings

Background: The 2007 Appropriate Use Criteria (AUC) for echocardiography was revised in 2011 to cover a wider range of scenarios of use. Previous studies of the 2007 AUC found a relatively large number of unclassified transthoracic echocardiograms (TTEs).

Methods: We conducted a retrospective chart review comparing TTE usage in three clinical environments: academic inpatient, academic outpatient, and community outpatient. We assessed the TTE ordering behavior using both the 2007 and 2011 AUC.

Results: We reviewed 150 consecutive TTEs performed in 2011 in each of the three practice settings (total 450). Using the 2007 AUC, 347 TTEs (77%) were classifiable, and, using the 2011 AUC, 441 TTEs (98%) were classifiable (P < .001). Of the classified studies, the percentage of appropriate TTEs using the 2007 AUC was 83% and using the 2011 AUC was 71% (P < .001). Using the 2007 and 2011 AUC, the percentage of inappropriate TTEs was 17% and 22% (P = .14), and the percentage of uncertain TTEs was 0% and 7% (P < .001), respectively. The rate of inappropriate studies was greatest in the outpatient academic medical center (30%), followed by the outpatient community health center (21%) and the inpatient academic medical center (14%; P = .004).

Conclusions: The 2011 AUC classified a significantly greater proportion of TTEs than the 2007 AUC across a variety of practice settings. The rate of appropriate TTEs was lower using the 2011 AUC, and the appropriateness ratings varied by clinical setting. These findings suggest that the expanded AUC offer an opportunity for improvement in TTE usage.