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Clinical Practice Guidelines Decrease Unnecessary Echocardiograms Before Hip Fracture Surgery
Chris Adair1, Eric Swart, Rachel Seymour
11Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina.
Insights
Preoperative transthoracic echocardiography (TTE) for hip fracture patients is often not aligned with clinical practice guidelines (CPGs). Adhering to guidelines can reduce unnecessary TTE use without missing critical cardiac conditions.
Area of Science:
- Cardiology
- Geriatric Medicine
- Anesthesiology
Background:
- Preoperative transthoracic echocardiography (TTE) for geriatric hip fracture patients is resource-intensive and can delay surgery.
- Current utilization patterns of TTE in this population are not well-defined.
- The study addresses the need to optimize TTE use in preoperative cardiac assessment.
Purpose of the Study:
- To evaluate preoperative TTE utilization in geriatric hip fracture patients.
- To determine adherence to clinical practice guidelines (CPGs) for TTE ordering.
- To assess the impact of CPG adherence on resource utilization and detection of actionable cardiac disease.
Main Methods:
- Retrospective review of 100 geriatric hip fracture patients who underwent preoperative TTE.
- Evaluation of TTE ordering against American College of Cardiology/American Heart Association (ACC/AHA) CPGs.
- Analysis of TTE reports for clinically significant cardiac findings impacting management.
Main Results:
- TTE was ordered according to ACC/AHA CPGs in 66% of patients.
- Clinically significant cardiac disease, altering management, was found in 14% of patients, all indicated by guidelines.
- Following CPGs could have prevented 34% of TTEs without missing important disease (40% specificity).
Conclusions:
- Preoperative TTE for hip fracture patients is frequently used outside established CPG recommendations.
- Implementing ACC/AHA guidelines can decrease variability in care and reduce unnecessary resource utilization.
- Adherence to CPGs for TTE may optimize patient management and resource allocation without compromising outcomes.
Background:
Preoperative assessment of geriatric patients with a hip fracture may include transthoracic echocardiography (TTE), which increases resource utilization and cost and may delay surgery. The purpose of this study was to evaluate preoperative TTE utilization at a single institution in order to determine (1) how often TTE is ordered in accordance with clinical practice guidelines (CPGs), (2) how frequently TTE reveals cardiac disease that may alter medical or anesthesia management, and (3) whether following CPGs reduces unnecessary TTE utilization without potentially missing important disease.
Methods:
A retrospective review of data on 100 geriatric patients with a hip fracture who had undergone preoperative TTE was performed. Charts were reviewed to evaluate if TTE had been obtained in accordance with the published CPGs from the American College of Cardiology/American Heart Association (ACC/AHA). TTE reports were reviewed for the presence of disease that was important enough to cause modifications in anesthesia or perioperative management, including new left ventricular systolic or diastolic dysfunction, moderate or severe valvular disease, and pulmonary hypertension. Finally, the sensitivity and specificity of accordance with the ACC/AHA CPGs for predicting which patients would have TTE that identified important disease were calculated.
Results:
The TTE was ordered in accordance with the published ACC/AHA CPGs for 66% of the patients. TTE revealed disease with the potential to modify anesthesia or medical management in 14% of the patients-for all of whom the TTE had been indicated according to ACC/AHA guidelines (i.e., the guidelines were 100% sensitive). In this study population, following the ACC/AHA guidelines could have prevented the performance of TTE in 34% of the patients without missing any disease (40% specificity).
Conclusions:
Preoperative TTE for patients with a hip fracture is frequently obtained outside the recommendations of established CPGs. Utilization of CPGs such as the ACC/AHA guidelines should be considered, as it may decrease variability in care and reduce unnecessary resource utilization without adversely affecting patient outcomes.