Background

Preoperative resting echocardiography is often performed before noncardiac surgery, but indications for preoperative resting echocardiography are limited. This study aimed to investigate appropriateness of preoperative resting echocardiography using the Appropriate Use Criteria for Echocardiography, which encompass indications from the guidelines on perioperative cardiovascular evaluation and management and nonperioperative indications independent of the perioperative period. The authors hypothesized that patients are frequently tested without an appropriate indication.

Methods

Records of patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent a major abdominal surgery from 2005 to 2017 were included. These databases contain de-identified records of health services for more than 250 million patients with primary or Medicare supplemental health insurance coverage through employer-based fee-for-service, point-of-service, or capitated plans. Patients were classified based on the presence of an outpatient claim for resting transthoracic echocardiography within 60 days of surgery. Appropriateness was determined via International Classification of Diseases, Ninth Revision–Clinical Modification, and International Classification of Diseases, Tenth Revision–Clinical Modification principal and secondary diagnosis codes associated with the claims, and classified as “appropriate,” “rarely appropriate,” or “unclassifiable” using the Appropriate Use Criteria for Echocardiography.

Results

Among 230,535 patients in the authors’ cohort, preoperative resting transthoracic echocardiography was performed in 6.0% (13,936) of patients. There were 12,638 (91%) studies classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Among the classifiable studies, 8,959 (71%) were deemed “appropriate,” while 3,679 (29%) were deemed “rarely appropriate.” Surveillance of chronic ischemic heart disease and uncomplicated hypertension accounted for 43% (1,588 of 3,679) of “rarely appropriate” echocardiograms.

Conclusions

More than one in four preoperative resting echocardiograms were considered “rarely appropriate” according to the Appropriate Use Criteria for Echocardiography. A narrow set of patient characteristics accounts for a large proportion of “rarely appropriate” preoperative resting echocardiograms.

Editor’s Perspective
What We Already Know about This Topic
  • Resting echocardiography is often performed before noncardiac surgery, and its utilization can be evaluated using the American College of Cardiology Foundation Appropriate Use Criteria for Echocardiography

  • The Center for Medicare and Medicaid Services will begin requiring providers to demonstrate adherence to appropriate use criteria when ordering advanced imaging studies beginning in 2022

What This Article Tells Us That Is New
  • Among 230,535 patients in a national claims database between 2005 and 2017, 13,936 (6.0%) underwent resting echocardiography within 60 days before surgery, and 12,638 could be classified using the Appropriate Use Criteria for Echocardiography

  • More than a quarter of all resting echocardiograms (3,679 of 12,638; 29%) were deemed “rarely appropriate,” while 71% (8,959 of 12,638) were deemed “appropriate”

  • Surveillance of chronic ischemic heart disease and a diagnosis of uncomplicated hypertension accounted for 43% (1,588 of 3,679) of the “rarely appropriate” preoperative resting echocardiograms

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