Appropriateness use criteria for transthoracic echocardiography: relationship with radiology benefit managers preauthorization determination and comparison of the new (2010) criteria to the original (2007) criteria.

BACKGROUND: In response to growth in cardiac imaging, medical societies have published appropriateness use criteria (AUC) and payers have introduced preauthorization mandates, largely through radiology benefits managers (RBM). The correlation of algorithms used to determine preauthorization with the AUC is unknown. In addition, studies applying the 2007 AUC for transthoracic echocardiography revealed that many echocardiograms could not be classified. We sought to examine the impact of the revised 2010 AUC on appropriateness ratings of transthoracic echocardiograms previously classified by the 2007 AUC and the relationship of preauthorization determination to AUC rating. METHODS: We reclassified indications for transthoracic echocardiography as appropriate, inappropriate, uncertain, or unclassifiable using the 2010 AUC in the same 625 patients previously reported using 2007 AUC. We also evaluated the relationship between preauthorization status by 2 RBM precertification algorithms and appropriateness rating by 2007 AUC. RESULTS: The appropriateness classification of 148 (24%) transthoracic echocardiograms was changed by the updated AUC (P < .001). The number of unclassifiable echocardiograms was markedly reduced from 99 (16%) to 8 (1%), and more echocardiograms were classified as inappropriate (95 [15%] vs 45 [7%]) or uncertain (43 [7%] vs 0 [0%]). Limited correlation between the 2007 AUC rating and RBM preauthorization determinations was noted, with only moderate agreement with RBM no. 1 (90%, κ = 0.480, P < .001) and poor agreement with RBM no. 2 (72%, κ = 0.177, P < .001). CONCLUSION: The updated AUC (2010) provide enhanced clinical value compared with 2007 AUC. There is limited agreement between RBM preauthorization determination and 2007 AUC rating.

Adherence to appropriateness criteria for transthoracic echocardiography: comparisons between a regional department of Veterans Affairs health care system and academic practice and between physicians and mid-level providers.

We compared adherence to appropriateness criteria for transthoracic echocardiography in a Veterans Administration Medical Center (VAMC) and an academic practice and, within the VAMC, between physicians and mid-level providers. We reviewed 201 outpatient echocardiograms performed in the laboratory of an academic practice and 424 outpatient and inpatient studies performed at a VAMC. Echocardiographic examinations requested for indications addressed in the criteria were considered classified, and those for indications not addressed were considered unclassified. Classified studies were further rated as appropriate or inappropriate. Of 625 echocardiograms reviewed, 99 (16%) were unclassified. Approximately 80% of the indications for these could be assigned to 4 categories. Of the remaining 526 echocardiograms, indications were appropriate in 481 (91.4%) and inappropriate in 45 (8.6%). Among classified outpatient studies at the VAMC, mid-level providers requested significantly more studies for inappropriate indications than physicians (16.0% vs 7%, P = .024). There was no significant difference in the frequency of outpatient studies requested for inappropriate indications by VAMC and academic practice physicians (7.0% vs 9.5%, P = .558). The appropriateness criteria perform reasonably well at evaluating variations in use of echocardiography between health care systems and providers. The large majority of studies are requested for appropriate indications, although there is room for improvement.