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Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary
Tharmegan Tharmaratnam1,2, Zachary Bouck2,3, Atul Sivaswamy4
1School of Medicine, Royal College of Surgeons in Ireland, Dublin (T.T.).
Insights
Cardiologists ordering frequent, rarely appropriate echocardiograms for coronary artery disease (CAD) patients were linked to reduced high-value care and increased mortality. This highlights potential practice pattern impacts on patient outcomes.
Area of Science:
- Cardiology
- Health Services Research
- Clinical Practice Patterns
Background:
- The impact of ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not well understood.
- Investigating practice patterns of cardiologists with high rates of low-value echocardiogram orders in CAD patients is crucial to understand their influence on patient outcomes.
Purpose of the Study:
- To investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with coronary artery disease (CAD).
- To determine if these practice behaviors influence patient outcomes.
Main Methods:
- A retrospective cohort study included 3966 outpatient CAD patients who visited one of 35 Ontario-based cardiologists from the EchoWISELY trial control group.
- Patients were stratified into three tertiles based on their cardiologist's ordering frequency of rarely appropriate transthoracic echocardiograms.
- Outcomes assessed at 1 year included diagnostic tests, physician visits, medication prescriptions, and clinical outcomes.
Main Results:
- Patients of cardiologists in the top tertile for rarely appropriate echocardiogram orders had significantly lower odds of receiving cholesterol assessment (OR, 0.77) and hemoglobin A1c assessment (OR, 0.79) at 1 year.
- These patients also had lower odds of receiving beta-blocker (OR, 0.70) and aldosterone receptor antagonist (OR, 0.46) prescriptions.
- Conversely, patients of high-ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54).
Conclusions:
- Cardiologists with high rates of ordering rarely appropriate transthoracic echocardiograms in CAD patients were associated with reduced receipt of potentially high-value screening tests and evidence-based medications.
- These practice patterns may negatively impact patient outcomes, including increased all-cause mortality.
Background:
The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes.
Methods And Results:
A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar.
Conclusions:
Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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