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”.