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Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists
J R Lopes1, A C Oliveira1, V G Rios2
1Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil.
Insights
Inappropriate echocardiograms rarely yield significant findings, yet patients perceive them as necessary. Cardiologists and patients significantly disagree on the usefulness of these cardiac imaging tests.
Area of Science:
- Cardiology
- Medical Imaging
- Health Services Research
Background:
- Inadequate diagnostic tests offer low benefit-risk ratios but are common.
- Patient perceptions of the utility of unnecessary cardiac imaging are poorly understood.
- Echocardiography is a widely used cardiac imaging modality.
Purpose of the Study:
- To identify relevant findings in echocardiograms ordered for inappropriate indications.
- To compare patient and cardiologist agreement on the usefulness of these echocardiograms.
Main Methods:
- Retrospective analysis of echocardiograms performed on adults without known cardiovascular disease referred under inappropriate criteria.
- Relevant findings defined as moderate-to-severe changes per American Society of Echocardiography guidelines.
- Patient and cardiologist agreement assessed via questionnaire regarding test necessity.
Main Results:
- Only 3.4% of inappropriate echocardiograms revealed relevant findings (e.g., valve changes, diastolic dysfunction).
- A significant disparity exists in perceived necessity: 92% of patients found the test necessary versus 5% of cardiologists.
- Low agreement (Kappa -0.04) between patients and cardiologists on test usefulness was observed.
Conclusions:
- Inappropriate echocardiograms yield few relevant findings, indicating low diagnostic yield.
- Patients overestimate the necessity and usefulness of cardiac imaging compared to referring cardiologists.
- This discrepancy highlights a need for improved patient-physician communication and judicious test ordering in cardiology.
Abstract:
Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.
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