Less Than One-Third of TTEs Lead to Change in Patient Care

Although almost all transthoracic echocardiograms (TTEs) were deemed appropriate, only 1 in 3 resulted in an active change in the patient’s care and about 1 in 5 resulted in no change in care, according to results of a recent study [JAMA Intern Med. 2013;173:1600-1607].

Susan A. Matulevicius, MD, University of Texas Southwestern Medical Center, and her colleagues conducted a study to examine the proportion of TTEs that affect clinical care in an academic medical center. The researchers retrospectively reviewed all TTEs ordered at the University of Texas Southwestern Medical Center in April 2011. Two independent general cardiologists classified TTEs according to AUC, and 2 noninvasive cardiologists independently assessed the clinical impact of each TTE according to 3 categories: (1) active change in care; (2) continuation of care; and (3) no change in care.

Continuation of care was defined as no escalation or de-escalation of care, but TTE results were documented and/or the results provided to patients. No change in care meant the TTE results had no effect on the patient’s care whatsoever and no documentation of reassurance about TTE findings was completed.

The researchers rated TTEs that led to active change on a scale of 1 to 5, with “1” considered to be misused, and “5” classified as very useful. Differences in frequency distributions were statistically compared using the Pearson’s chi-squared test, and differences in continuous variables were compared using analysis of variance. A total of 535 TTEs were included in the study. Results showed that 91.8% of all TTEs were classified as appropriate, 4.3% as inappropriate, and 3.9% as uncertain. Most outpatient and inpatient TTEs were deemed appropriate (86.5% vs 95.7%; P<0.001). The 10 most frequent AUCs, which were all classified as appropriate, comprised 66.5% of TTEs resulting in active change in care, 69.3% of TTEs resulting in no change in care, and 66.5% of TTEs resulting in continuation of care.

In the overall cohort, 31.8% of TTEs led to an active change in care, 46.9% resulted in continuation of current care, and 21.3% led to no change (see Figure below). Results of the exploratory analysis showed that among the TTEs that did lead to active change, 18.9% were categorized as “5” (very useful) or “4” (useful), and 6% were classified as “2” (not useful) or “1” (misused).

“This suggests that only 1 out of every 10 TTEs was affecting care in a meaningful way,” Dr. Matulevicius said. “This presents an opportunity for the medical community to reassess the value of frequently used diagnostic testing, like echocardiograms, in the daily care of patients.” 

Older patients and inpatients were more likely to have TTEs leading to no change (P=0.003 and P<.001, respectively). Cardiology was also associated with a lower proportion of TTEs resulting in no change in care (12.6%) compared with pulmonary/critical care and surgery (39%; P<.001, and 31.5%; P=.004, respectively). The most common active changes included further diagnostic testing (29.4%) or subspecialty consultation (29.5%).

Limitations of the study include its retrospective design, which relied on electronic medical record review, and was therefore subject to incomplete documentation and consequently possible misclassification of impact. Also, differences may exist in adherence to AUC according to region, practice size, and practice type, among other variables, and could not be obtained.

Dr. Matulevicius concluded, “As a professional community, we must acknowledge the spectrum of value in testing and try to refrain from ordering a TTE just because it is part of the ‘protocol’ for evaluating a given condition, if it provides very little necessary information. At the same time, we must realize that sometimes information that informs and supports a decision to continue our current management of a patient, but does not actively change care, is equally important. It is our responsibility to better define the use of all diagnostic testing in our care of patients and to be stewards of our healthcare resources.”