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.

Effects of weight loss after gastric bypass on right and left ventricular function assessed by tissue Doppler imaging.

To evaluate the effects of substantial weight loss on tissue Doppler imaging parameters of right ventricular (RV) and left ventricular (LV) systolic and diastolic function, we performed standard echocardiography and tissue Doppler imaging in 17 patients with severe obesity before and after gastric bypass. Patients lost 39 +/- 10 kg over 7.6 +/- 3.6 months. Adjusted LV mass decreased (134 +/- 41 to 119 +/- 31 kg/m, p = 0.031). After weight loss, the ratios of early-to-late diastolic mitral and tricuspid inflow velocities increased (1.3 +/- 0.2 to 1.6 +/- 0.5, p = 0.02; 1.0 +/- 0.1 to 1.6 +/- 0.3, p = 0.003). Early diastolic tissue Doppler velocities increased at both the lateral and septal mitral annulus (7.6 +/- 1.5 to 9.3 +/- 2.5 cm/s, p = 0.009; and 6.6 +/- 1.4 to 7.7 +/- 1.7 cm/s; p = 0.028, respectively) and for their 2-site average (7.2 +/- 1.0 to 8.5 +/- 1.7 cm/s, p = 0.007). Early diastolic tricuspid annular velocity increased (7.2 +/- 2.8 to 10.6 +/- 2.3 cm/s, p <0.001) as did the ratio of early-to-late tricuspid annular diastolic velocity (0.9 +/- 0.4 to 1.1 +/- 0.2, p = 0.038). Tricuspid annular systolic velocity increased (8.6 +/- 2.5 to 10.3 +/- 2.7 cm/s, p = 0.037). In patients with severe obesity, significant weight loss results in an increase in tricuspid annular systolic and early diastolic velocities and mitral annular early diastolic velocities.

Tissue Doppler imaging of the right and left ventricle in severe obesity (body mass index >35 kg/m2).

We investigated right and left heart function in 51 patients with a body mass index of >35 kg/m(2) who underwent evaluation for gastric bypass surgery using standard Doppler echocardiography and color tissue Doppler imaging. Left atrial diameter (3.7 +/- 0.5 vs 3.3 +/- 0.4 cm, p <0.001), left ventricular end-diastolic diameter (5.0 +/- 0.6 vs 4.5 +/- 0.4 cm, p <0.001), and left ventricular mass index (119 +/- 49 vs 76 +/- 26 g/m, p <0.001) were increased in patients with severe obesity. Early diastolic mitral annular velocity (7.5 +/- 2.1 vs 9.6 +/- 3.0 cm/s, p <0.001), early diastolic/late diastolic mitral annular velocity ratio (1.38 +/- 0.6 vs 1.94 +/- 1.3, p = 0.007), early diastolic tricuspid annular velocity (7.8 +/- 2.6 vs 9.5 +/- 2.4 cm/s, p = 0.002), early diastolic/late diastolic tricuspid annular velocity ratio (0.9 +/- 0.36 vs 1.1 +/- 0.4, p = 0.048), and mitral annular systolic velocity (5.7 +/- 1.3 vs 6.5 +/- 1.5 cm/s, p = 0.012) were significantly lower in obese patients. Early diastolic mitral inflow/mitral annular velocity ratio was increased in the obese (13.5 +/- 4.7 vs 9.1 +/- 3.6, p <0.001). Tricuspid annular systolic velocities did not differ.