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doi:10.1016/j.

Evaluation of the Clinical Application of the ACCF/ASEAppropriateness Criteria for Stress Echocardiography

Ibrahim N. Mansour, MD, Roberto M. Lang, MD, FASE, Waseem M. Aburuwaida, MD, Nicole M. Bhave, MD,and R. Parker Ward, MD, FASE, Chicago, Illinois

Background: The aim of this study was to evaluate the clinical application of the American College ofCardiology Foundation and American Society of Echocardiography appropriateness criteria for stressechocardiography (SE) in a single-center university hospital.

Methods: Indications were determined for consecutive studies by two reviewers and categorized as appropri-ate, uncertain, or inappropriate.

Results: Of 477 studies for which primary indications could be determined, 188 specifically related to universitytransplantation programs were excluded. Of the remaining 289 studies, 88% were addressed in the appropriate-ness criteria for SE. Of these, 71% were appropriate, 9% were uncertain, and 20% were inappropriate. Inappro-priate studies were more likely to be ordered on younger patients and womenand were less likely to be ordered bycardiologists. Abnormal results on SE were more frequent among appropriate than inappropriate studies.

Conclusions: The appropriateness criteria for SE encompass and effectively characterize the majority ofstudies ordered in a single-center university hospital and appear to reasonably stratify the likelihood of abnor-mal results on SE. However, revisions will be required to fully capture and stratify appropriate clinical practice ofSE. (J Am Soc Echocardiogr 2010;23:1199-204.)

Keywords: Appropriateness criteria, Stress echocardiography, Clinical application

The dramatic increase in the utilization of cardiovascular diagnosticimaging over the past decade is undeniable. Diagnostic imagingservices reimbursed under Medicare’s physician fee schedule grewmore rapidly than any other type of physician service from 1999 to2003.1,2 This increased utilization has resulted in increased scrutinyof the appropriate use of cardiac imaging services.1,2 In response, theAmerican College of Cardiology Foundation (ACCF) in conjunctionwith imaging subspecialty societies has published appropriatenesscriteria (AC) for selected patient indications for a variety of imagingmodalities.3-8 The goal of these documents is to guide physiciansand reimbursement agencies in determining a rational approach tothe use of diagnostic imaging in the delivery of high-quality care.

Recently, the ACCF and American Society of Echocardiography(ASE) AC for stress echocardiography (SE) were published.3 Aswith other AC documents, these criteria use a standardized method-ology, combining available evidence with expert opinion to identifycommon indications for SE and to determine their level of appropri-

-Invasive Imaging Laboratories, Section of Cardiology, Department

niversity of Chicago, Chicago, Illinois.

s sponsored by a grant from the American Society of Echocardiog-

ille, NC).

sts: R. Parker Ward, MD, University of Chicago Medical Center, 5841

Avenue, RM 611B, MC6080, Chicago, IL 60637 (E-mail: pward@

.uchicago.edu).

6.00

0 by the American Society of Echocardiography.

echo.2010.07.008

ateness.3-8 Similar AC for nuclear stress testing were first published in2005 and then revised in 2009, after a number of investigationsassessing their implementation in routine clinical practice identifiedgaps and improvements that were necessary.5,6,9 The ACCF andASE are currently working to develop a revision of the AC forechocardiographic procedures. Although a number of studies haveassessed the clinical application of the AC in transthoracic andtransesophageal echocardiography, limited experience with theapplication of the AC for SE has been published.10-15

Thus, the purposes of this study were to investigate the feasibility ofclinical application of the published AC for SE and to describe their ap-plication to current clinical practice at a single-center universityhospital.

METHODS

Consecutive patients referred for exercise or pharmacologic SE at theUniversity of Chicago Medical Center between May 2008 andDecember 2008 were eligible for inclusion. The protocol wasapproved by the institutional review board, and all patients providedinformed consent. For each study, patient demographic information,referring physician specialty, outpatient or inpatient status, the pri-mary indication for the study, and the results of the SE were recorded.For this analysis, SE performed for hemodynamic evaluation and forviability assessment were excluded.

Indication Determination

For each study, written requisitions and hospital and practice recordswere reviewed. A primary indication for each study was determined

1199

Abbreviations

AC = Appropriateness criteria

ACCF = American College of

Cardiology Foundation

ASE = American Society ofEchocardiography

CAD = Coronary arterydisease

ECG = Electrocardiogram

NA = Not addressed

SE = Stress

echocardiography

1200 Mansour et al Journal of the American Society of EchocardiographyNovember 2010

independently by two physicianinvestigators blinded to the re-sults of the SE. Investigatorswere asked to select one of twooptions; (1) one of the indica-tions listed in the AC for SE or(2) not addressed (NA; the pri-mary indication of the studywas NA in the AC for SE). A pri-mary consensus indication foreach study was then determinedfor all further analysis. For studiesin which the two investigatorswere in agreement, the indica-tion and category selected servedas the final primary consensus in-

dication. For those studies in which there was disagreement betweenthe two investigators, a third investigator independently reviewed thedata and chose one of the two initial selections as a final primaryconsensus indication.

SE

All stress echocardiographic studies were performed according to thepreferred recommendations of the ASE using a full platform echocar-diographic instrument (iE33; Philips Medical Systems, Andover,MA).16 All studies were interpreted by one of seven expert echocardi-ographers, and the findings used for analysis in this study representthose reported on the final clinical echocardiographic report. Exercisetesting consisted of symptom-limited exercise treadmill testing usinga Bruce protocol, with baseline and peak stress imaging. All standardexercise testing parameters were recorded. Pharmacologic testingwas performed with dobutamine using a standard rest, low-dose(5–10 mg/kg/min), high-dose (20–50 mg/kg/min), and recovery imag-ing protocol, with atropine supplementation (up to 1 mg) if necessaryto achieve 85% of the maximum predicted heart rate response.Echocardiographic contrast was used if two or more contiguous endo-cardial segments were not visible on baseline images.

Abnormal results on SE were defined as any echocardiographicfinding suggesting inducible myocardial ischemia, including anynew stress-induced wall motion abnormality, stress-induced worsen-ing of an existing wall motion abnormality, and/or stress-induced leftventricular dysfunction or chamber enlargement.

Statistical Analysis

Comparisons between study and patient characteristics, findings onSE, and levels of appropriateness were performed with c2 tests forcategorical data and Student’s t tests for continuous data usinga two-tailed p value < .05 for statistical significance. Interobservervariability in the determination of indication, category, and level ofappropriateness is expressed as percentage agreement between thetwo independent reviewers. For indication and category determina-tion, interobserver comparisons represent the frequency withwhich the reviewers agreed on the indication number or category(i.e., indication number or NA). For determination of level ofappropriateness, interobserver comparisons represent the frequencywith which reviewers selected indications with matching levels ofappropriateness (appropriate vs inappropriate vs uncertain), thoughnot necessarily an identical indication number. Studies for whichboth reviewers chose NA, and thus no appropriateness level was

available for either reviewer selection, were excluded from compari-sons of appropriateness level.

RESULTS

Overall, 517 studies were enrolled. Of these, 8% (n = 40) wereexcluded because of insufficient evidence to determine the primaryindication. Additionally, in an effort to maximize the applicability ofour results to the broad practice of SE, studies that were specificallyrelated to stress testing protocols as part of solid organ transplantationprograms at our institution (36% [n = 188]) were excluded, leavinga final study group of 289 studies.

Of this study group, 93% (n = 268) were outpatient studies, and 7%(n = 21) were inpatient studies. The mean patient age was 59 6 18years, and 49% (n = 141) of studies were performed on women(Table 1). Fifty-one percent of the patients (n = 145) underwent dobut-amine SE, and 49% (n = 144) underwent exercise SE. Cardiology wasthe most common referring specialty (45% [n = 130]), followed byinternal medicine or primary care (27% [n = 78]), and anesthesiologyfrom a preoperative evaluation clinic at our institution (25% [n = 71])(Table 2).

Of the final study group, 88% (n = 253) were ordered for indica-tions outlined in the AC document, while 12% (n = 36) were orderedfor indications NA by the document. Of the 253 studies for which theAC document could be applied, 71% (n = 180) studies wereappropriate, 9% (n = 23) were uncertain, and 20% (n = 50)(Figure 1) were inappropriate studies. The frequency of studies ineach AC table and the frequency of studies ordered for the most com-mon indications as outlined the AC document are summarized inTables 3 and 4, respectively. The most common indication for SEwas indication 3, ‘‘Evaluation of chest pain syndrome or anginalequivalent in patients with intermediate pre-test probability of CAD[coronary artery disease] who have an interpretable ECG [electrocar-diogram] who are able to exercise,’’ accounting for 34% of all studies.

Inappropriate studies were more likely to be ordered on women(23% of studies ordered on women were inappropriate vs 16% ofstudies ordered on men, P = .03) and younger patients (mean agefor appropriate studies, 50 6 18 years vs 63 6 12 years for appropri-ate studies; P < .001). Cardiologists were less likely to order inappro-priate studies compared with noncardiologists (15% of inappropriatestudies vs 24% of inappropriate studies, P < .05). Inappropriate stud-ies were most frequently ordered by anesthesiologists from an anes-thesia preoperative clinic at our institution (46% of all inappropriatestudies; Table 2). Among studies ordered for preoperative assessment,cardiologists had 4% inappropriate studies (one of 25), internal med-icine or primary care physicians had 0% inappropriate studies (zero ofsix), and anesthesiologists had 51% inappropriate studies (19 of 37)(P < .001, anesthesiologist-ordered vs non-anesthesiologist-orderedpreoperative studies).

Indication 1 (‘‘Evaluation of chest pain syndrome or anginal equiv-alent in patients with low pre-test probability of CAD who have aninterpretable ECG and able to exercise’’) was the most commoninappropriate indication, accounting for 44% of all inappropriateindications. The frequencies of the five most commonly ordered inap-propriate studies (accounting for >95% of all inappropriate studies)are summarized in Table 5.

Categories of indications for which the NA studies were orderedare listed in Table 6. The most common indications were thoseinvolving preoperative evaluation for noncardiac surgery, which are

Table 1 Study characteristics for all stress echocardiographic studies according to level of appropriateness as outlined in the ACfor SE

All studies

(n = 289)

Appropriate indication

(n = 180)

Inappropriate indication

(n = 50)

Uncertain indications

(n = 23)

NA studies

(n = 36)

Age (years) 59 6 18 63.3 6 12 50 6 18† 66.4 6 12‡ 55 6 16

Women 51% (147) 46% (82) 64% (32)* 43% (10) 65% (23)

Outpatients 93% (268) 91% (163) 98% (49) 100% (23) 93% (33)

Data are expressed as mean 6 SD or percentage number.

*P < .05 vs appropriate studies.

†P < .01 vs appropriate studies.‡P < .0.01 vs inappropriate studies.

Table 2 Ordering physician referral characteristics for all stress echocardiographic studies according to level of appropriatenessas outlined in the AC for SE

Ordering physician specialty

All studies

(n = 289)

Appropriate indication

(n = 180)

Inappropriate indication

(n = 50)

Uncertain indications

(n = 23)

NA studies

(n = 36)

Cardiology 45% (130) 49% (89) 36% (18)* 57% (13)† 29% (10)

Internal medicine/primary care 27% (78) 28% (50) 18% (9)* 30% (7)† 34% (12)†

Anesthesiology (preoperative clinic) 25% (71) 18% (32) 46% (23)* 9% (2)† 37% (14)

Other 3% (10) 5% (9) 0% 4% (1) 0%

Data are expressed as percentage (number).

*P < .01 vs appropriate studies.

†P < .0.01 vs inappropriate studies.

0

10

20

30

40

50

60

70

80

AppropriateInappropriateUncertain

%%

Figure 1 Appropriateness classification for SE with indicationsaddressed in the AC for SE (n = 253).

Table 3 Distribution of stress echocardiographic studies asa function of table number for all stress echocardiographicstudies according to level of appropriateness as outlined inthe AC for SE

Table number

% (number of studies)

(n = 253)

Appropriate

(n = 180)

Inappropriate

(n = 50)

Uncertain

(n = 23)

1 56.5% (143) 85% 15% 02 9.9% (25) 0 24% 76%

3 1.6% (4) 75% 0 25%4 0.8% (2) 50% 0 50%

5 28.5% (72) 72% 0 28%6 0.4% (1) 100% 0 0

7 1.2% (3) 67% 33% 08 0 0 0 0

9 1.2% (3) 0 33% 67%

Journal of the American Society of EchocardiographyVolume 23 Number 11

Mansour et al 1201

NA in the current version of the AC for SE, accounting for 36% of allNA studies. Indications involving electrocardiographic abnormalitiesor cardiac arrhythmias such as premature ventricular contractions,nonspecific ST-segment changes, left bundle branch block, andT-wave inversions were also common, accounting for 29% of NAstudies.

Overall, 11% of stress echocardiographic studies in the study groupwere found to have echocardiographic evidence of myocardialischemia, with abnormal studies in 2% of inappropriate, 8% ofuncertain, 14% of appropriate, and 8% of NA studies. Abnormalresults were significantly more frequent in appropriate comparedwith inappropriate studies (14% vs 2%, P = .03; Figure 2).

Analysis of interobserver variability for indication determinationrevealed that the two initial independent reviewers had 76%agreement on the determination of indication and category (indicationnumber, NA). In 92% of cases, they selected indications with the samelevels of appropriateness (appropriate, uncertain, or inappropriate).

DISCUSSION

In this study, we found that the AC for SE encompasses the majority ofindications for SE ordered in routine clinical practice at a single-centeruniversity hospital and that a majority of the studies are ordered forappropriate indications. The AC for SE also appears to reasonablystratify stress test ordering, as appropriate studies were found tohave significantly more abnormal results than inappropriate studies.After excluding studies that were specifically related to the universitytransplantation program, we found that there remained a smallnumber of studies (12%) in our clinical practice that are NA by theAC for SE, suggesting that the ongoing revisions of this document

Table 5 Most common inappropriate indications for stress echocardiographic studies performed in an academic institution aslisted in the AC for SE (accounting for 96% of all stress echocardiographic studies with inappropriate indications)

Indication as listed in the AC for SE

Inappropriate indications

(n = 50)

Indication 1: ‘‘Evaluation of chest pain syndrome or anginal equivalent in patients with low pre-test

probability of CAD who have an interpretable ECG and able to exercise’’

44%

Indication 29: ‘‘Pre-operative evaluation for an intermediate-risk non-cardiac surgery in patients withpoor exercise tolerance (less than or equal to 4 METs), and minor or no clinical risk predictors’’

26%

Indication 28: ‘‘Pre-operative evaluation for a low-risk non-cardiac surgery in patients with minor

or intermediate clinical risk predictors’’

14%

Indication 12: ‘‘Detection of CAD and risk assessment in asymptomatic (without chest pain syndrome

or anginal equivalent) general patient populations with moderate CHD risk (Framingham risk criteria)and an interpretable ECG’’

8%

Indication 11: ‘‘Detection of CAD and risk assessment in asymptomatic (without chest pain syndromeor anginal equivalent) general patient populations with low CHD risk (Framingham risk criteria)’’

4%

CHD, Coronary heart disease; MET, metabolic equivalent.

Table 4 Most common indications for stress echocardiographic studies performed in an academic institution as listed in the ACfor SE (accounting for 91% of all stress echocardiographic studies with indications covered in the AC for SE)

Indication as listed in the AC for SE

% of all studies for which indication

was covered in the AC for SE

(n = 253)

Indication 3: ‘‘Evaluation of chest pain syndrome or anginal equivalent in patients with intermediate pre-test

probability of CAD who have an interpretable ECG and who are able to exercise’’ (appropriate)

34%

Indication 30: ‘‘Pre-operative evaluation for an intermediate-risk noncardiac surgery in patients with poorexercise tolerance (less than or equal to 4 METs), and intermediate clinical risk predictors’’ (appropriate)

22%

Indication 4: ‘‘Evaluation of chest pain syndrome or anginal equivalent in patients with an intermediatepre-test probability of CAD who have an uninterpretable ECG or unable to exercise’’ (appropriate)

13%

Indication 1: ‘‘Evaluation of chest pain syndrome or anginal equivalent in patients with Low pre-test

probability of CAD who have an interpretable ECG and able to exercise’’ (inappropriate)

9%

Indication 13: ‘‘Detection of CAD and risk assessment in asymptomatic (without chest pain syndrome or

anginal equivalent) general patient populations with high CHD risk (Framingham)’’ (uncertain)

8%

Indication 29: ‘‘Pre-operative evaluation for an intermediate-risk non-cardiac surgery in patients with poor

exercise tolerance (less than or equal to 4 METs), and minor or no clinical risk predictors’’ (inappropriate)

5%

CHD, Coronary heart disease; MET, metabolic equivalent.

1202 Mansour et al Journal of the American Society of EchocardiographyNovember 2010

will be necessary to fully encompass and stratify the appropriateclinical practice of SE.

This study represents the second published study to evaluate theclinical application of AC for SE, and it is the first to investigate thecorrelation between appropriateness level and findings on SE.14 Weused prospective methodology in an attempt to identify the ‘‘true’’indication of each study. Using this approach, we found that it waspossible to identify primary indications for the majority of clinicallyordered studies. There remained a small number of studies for whichprimary indications could not be determined. This was largely relatedto an inability to access or the lack of recent medical records necessaryto accurately ascribe indications. This occurred more frequently in thisstudy of SE (8%) than in our prior study of transthoracic echocardiog-raphy (2%), despite identical methodology and institutional medicalrecord systems.11 This discrepancy highlights additional challengesin the application of AC for stress testing. For example, a numberof stress indications include Framingham risk assessment, whichrequires recent lipid values that are not always available. Overall,however, the application of the AC for SE was found to be feasibleand reproducible.

Studies ordered for indications NA by the AC document repre-sented a significant fraction of those ordered at our institution. Themajority of these were specifically related to stress protocols as partof transplantation programs at our institution. We elected to excludethese studies so that our results would be more applicable to thebroad clinical practice of SE. As a result, we still identified a smallbut important number of stress echocardiographic studies (12%)ordered for routine indications that are NA in the current versionof the AC for SE. The most common of these include scenarios involv-ing preoperative testing for noncardiac surgery and electrocardio-graphic abnormalities or arrhythmias that are NA. Our resultssuggest that addressing these areas, as well as the use of SE in solidorgan transplantation programs, should be important additions tothe upcoming revision of the AC for SE.

Studies determined to be inappropriate by the AC document weremore commonly ordered on female and younger patients. Thisfinding is likely related to use of the modified Diamond andForrester models in the AC to assess the pretest probability of CADin symptomatic patients and may not reflect more truly inappropriatetesting in women.17 For example, using the modified Diamond and

Table 6 Indications for SE that are NA in the AC for SE

Indication

Indication not covered

in the AC document

(n = 36)

Preoperative evaluation with scenario NA 36% (13)Arrhythmias (e.g., PVCs, benign SVT, nonspecific ST-wave changes, LBBB, T-wave inversions) 29% (14)

Syncope, dizziness, and lightheadedness 14% (5)Miscellaneous 11% (4)

Data are expressed as percentage (number).LBBB, Left bundle branch block; MET, metabolic equivalent; PVC, premature ventricular contraction; SVT, supraventricular tachycardia.

0

2

4

6

8

10

12

14

Appropriate Innapropriate Uncertain Not Addressed

%

Figure 2 Abnormal results on SE according to appropriatenessclassification. *p = .03 vs inappropriate studies.

Journal of the American Society of EchocardiographyVolume 23 Number 11

Mansour et al 1203

Forrester model, a man of any age with ‘‘atypical/probable anginapectoris’’ has an ‘‘intermediate’’ pretest probability of CAD and wouldbe considered appropriate for SE. A woman with the same symptomsaged < 50 years would have a ‘‘low’’ pretest probability of CAD andwould be considered inappropriate in the AC for SE. This gender biasappears to reflect an outdated approach to pretest probability assess-ment in women, in light of the wealth of recent evidence regardingthe impact and prevalence of ischemic heart disease in women.18,19

Our results appear to confirm the one prior report of the clinicalapplication of the AC for SE. McCully et al.14 found that 19% ofstress echocardiographic studies were not classifiable and that of theremaining studies addressed in the AC document, 66% were appro-priate, 24% were inappropriate, and 10% were uncertain studies. Thedefinition of ‘‘not classifiable’’ used in that study would equate to ourNA studies, plus those for which primary indications could not bedetermined. In our remaining cohort, the rates of appropriate(71%), inappropriate (20%), and uncertain (9%) studies werestrikingly similar.

Unlike McCully et al.’s14 study, our study also addresses therelationship between level of appropriateness and findings on SE. Wefound that the AC for SE successfully stratify indications according tothe likelihood of finding abnormal results, as studies with abnormal re-sults were significantly more common in appropriate compared withinappropriate studies. This suggests that in practice, the AC may in-crease the yield of clinically relevant findings from SE. It is importantto note, however, that findings on SE should not be the only determi-nant of whether SE was necessary or appropriate, because a normalstudy may provide important clinical information, such as excludingan ischemic etiology of dyspnea or chest pain and thus prompting ad-ditional workup or testing that may identify the cause.

The analysis of appropriateness according to ordering physicianspecialty reveals that cardiologists are less likely to order studies forinappropriate indications than noncardiologists. Although the reasonsfor this could not be determined in our study, it should be noted thatthe AC documents are designed to parallel evidence-based cardiovas-cular guidelines, which are likely best known by cardiac specialists.The physician specialty responsible for the largest fraction of inappro-priate studies (46%) was anesthesiology, from an anesthesia preoper-ative evaluation clinic in our institution. Although stress testing forpreoperative evaluation might be considered a more common settingfor potential inappropriate testing by all physicians, we found thatamong preoperative studies, anesthesiologists had a significantlyhigher rate of inappropriate testing than other specialties. Thisprovides one example of how specialty specific bias and trainingmay affect the appropriateness of stress testing and may guidetargeted educational interventions to limit inappropriate testing.Although this finding may not be portable to all other practice settings,

it highlights how tracking appropriateness can identify outliers towhom feedback and education about appropriate utilization can betargeted.

There were limitations of this study that deserve mention. First,because we evaluated the clinical practice of SE at a single-centeruniversity hospital, results may be different in other practice settings.Second, our study did not address the clinical impact of findings onSE. Therefore, we could not determine whether the results of thestress echocardiographic studies altered patient management, whichis the ultimate determinant of the true appropriateness of a diagnosticimaging study. We report the results of SE as a useful surrogate, but asmentioned, in certain scenarios, normal results on SE may be similarlyinfluential on a patient’s subsequent care as a study with abnormalresults. Finally, despite rigorous methodology, it is possible that ourprocess of indication determination may not have captured all clinicalconsiderations that led physicians to order SE.

CONCLUSIONS

The ACCF and ASE AC for SE were published in an effort to establisha rational approach to the use of SE in the delivery of high-qualitycare. Because these criteria may ultimately be used for reimburse-ment determinations, it is critical that they reflect and stratify theappropriate clinical practice of SE. We examined the clinicalapplication of these criteria and found that they successfully catego-rized most SE performed at our institution. The application of thesecriteria was found to be feasible, and they appear to successfullystratify test ordering according to likelihood of finding importantabnormalities on SE. However, we also identified a number ofrevisions of the AC for SE that will need to be addressed to allowroutine widespread clinical application of these criteria.

1204 Mansour et al Journal of the American Society of EchocardiographyNovember 2010

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