Appropriate use criteria for stress echocardiography: impact of updated criteria on appropriateness ratings, correlation with pre-authorization guidelines, and effect of temporal trends and an educational initiative on utilization

JACC Cardiovasc Imaging. 2013 Mar;6(3):297-309. doi: 10.1016/j.jcmg.2012.11.009. Epub 2013 Feb 20.


Objectives: This study evaluated utilization of stress echocardiography (SE) at our institution, the impact of the updated 2011 appropriate use criteria (AUC) on appropriateness ratings, correlation of AUC to radiology benefits managers' (RBM) pre-certification guidelines and the effect of temporal trends and an AUC-based educational project on appropriateness.

Background: The AUC for SE have been developed to improve efficiency of utilization and promote optimal patient care.

Methods: We classified the appropriateness of 209 SEs from 2008 using the original and updated AUC. We also performed pre-authorization determinations on these SEs using the guidelines of 2 RBMs. We then classified and compared the appropriateness of 209 SEs from 2011 using the updated criteria to that of the 2008 cohort. Finally, we rated and compared 111 SEs requested by cardiologists after an educational project to 111 SEs referred before the intervention.

Results: Overall, nearly one-third of SEs were requested for inappropriate indications. Using 2011 AUC, the original ratings of 52 (25%) studies by AUC 2008 were changed and the number of unclassified SE decreased from 20 (9.6%) to 2 (1%). Correlation between RBM pre-authorization determination and AUC ratings was substantial for the first RBM (κ = 0.625) and fair for the second (κ = 0.358). However, 12.9% and 41.9% of studies classified as appropriate or uncertain by the AUC would not have received pre-authorization according to the guidelines of the first and second RBMs, respectively. Referrals of inappropriate SE did not decrease over time or with an educational intervention.

Conclusions: The revisions in the updated AUC improve their clinical application by encompassing nearly all indications for SE. The limited correlation between AUC ratings and RBM determinations suggests a need for greater consistency. The large number of SE requested for inappropriate indications at our institution did not decrease with time or education.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • Adult
  • Aged
  • Algorithms
  • Area Under Curve
  • Chi-Square Distribution
  • Echocardiography, Stress / standards
  • Echocardiography, Stress / statistics & numerical data*
  • Education, Medical, Continuing*
  • Female
  • Florida
  • Guideline Adherence
  • Heart Diseases / diagnostic imaging*
  • Humans
  • Male
  • Medical Audit
  • Middle Aged
  • Patient Selection*
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'* / standards
  • Predictive Value of Tests
  • Referral and Consultation / standards
  • Referral and Consultation / statistics & numerical data*
  • Retrospective Studies
  • Time Factors
  • Unnecessary Procedures / standards
  • Unnecessary Procedures / statistics & numerical data*