Background
Over the past several decades, the use of non-invasive cardiac imaging
has increased faster than any other form of healthcare. The utilization
of transthoracic echocardiography has been estimated to grow at a rate
of approximately 6-8% per year.1,2 While this drastic
rise has helped to accelerate patient care and diagnose a broad spectrum
of cardiac pathology, a large number of imaging studies are ordered for
rarely appropriate indications. These rarely appropriate echocardiograms
have been reported to range from 6% to 23% of all ordered studies for
reference.3,4
The appropriate use criteria (AUC) for echocardiography were published
by the American College of Cardiology Foundation, the American Society
of Echocardiography, and other professional societies in 2007 in
response to the growing demand for the use of echocardiography. This
document was updated in 2011 reflecting new publications on this
topic.5 In 2013 a decision was made by the
professional societies to modify the terminology to better reflect
clinical practice and decision making.4,6 While older
documents used appropriate, uncertain, and inappropriate as the
criteria, all documents published after 2013 included appropriate, may
be appropriate, and rarely appropriate. A decision was also made to
write multimodality imaging documents which includes transthoracic,
transesophageal, and stress echo as well as all other modalities
available for cardiac imaging (nuclear stress test, CT, MRI, and
invasive angiography), instead of focusing on single modality, again,
reflecting clinical practice where more than one modality is available
to choose from.7,8 Various QI interventions were
developed to help incorporate the AUC guidelines into clinical practice.
To date, only few studies assessing the effectiveness of these
AUC-guided interventions in changing provider behavior have been
published, and their ability to reduce the performance of rarely
appropriate echocardiograms is not known. Most studies that are
available have been limited to single-center studies with limited
cohorts for comparison of QI intervention.
There have been very few systematic reviews currently looking at whether
AUC-guided interventions are an effective tool for reducing rarely
appropriate echocardiograms. High-quality meta-analysis is vital for
substantiating evidence to show the utility of the AUC guidelines. We
therefore conducted a systematic review and meta-analysis to evaluate
the effect of AUC quality improvement (QI) interventions aimed at
reducing rarely appropriate echocardiography testing. To capture older
publications and yet be consistent with the most updated AUC
terminology, both “inappropriate” and “rarely appropriate”
echocardiograms were included in our meta-analysis and were referred to
as “rarely appropriate”.