Prevalence of non-cardiac pathology on clinical transthoracic echocardiography.

BACKGROUND: Non-cardiac findings (NCFs) are seen in more than a third of cardiac computed tomographic and cardiac magnetic resonance imaging studies. The prevalence and importance of NCFs in transthoracic echocardiographic (TTE) imaging is unknown. The aim of this study was to determine the prevalence of NCFs on TTE imaging. METHODS: The subcostal images of all comprehensive adult TTE studies performed at one institution in December 2008 were retrospectively reviewed for NCFs by a radiologist with fellowship training in cardiovascular and abdominal radiology and blinded to the TTE report findings and clinical histories. Additional TTE image orientations were assessed in a subset of 300 studies. NCFs were categorized as benign (e.g., simple hepatic cyst), indeterminate (e.g., ascites), or worrisome (e.g., liver metastases). If an indeterminate or worrisome NCF was identified, the patient's electronic medical record was reviewed to determine if the NCF was previously known. RESULTS: Of 1,008 TTE studies (443 inpatient, 565 outpatient) in 922 patients, 77 NCFs were identified in 69 patients (7.5%). These included 20 benign (26%), 52 indeterminate (67%), and five worrisome (7%) NCFs. Intermediate and worrisome NCFs were more common in inpatient TTE studies (9% vs 3% outpatient, P = .002). The additional views demonstrated 2% more NCFs. Record review demonstrated that 60% of worrisome and 67% of indeterminate NCFs were previously known. No unknown NCF ultimately led to a change in patient management. CONCLUSIONS: Clinical TTE studies demonstrate NCFs in 7.5% of all patients, with an increased prevalence on inpatient studies. Although 75% of NCFs were potentially management changing, the majority of these were previously known and very unlikely to lead to management changes. Further study is needed to validate these findings in other populations and to assess their clinical impact.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned.

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

Using Digital Crumbs from an Electronic Health Record to identify, study and improve health care teams.

We have developed a novel approach, the Digital Crumb Investigator, for using data collected as a byproduct of Electonic Health Record (EHR) use to help define care teams and care processes. We are developing tools and methods to utilize these routinely collected data to visualize and quantify care networks across acute care and ambulatory settings We have chosen a clinical care domain where clinicians use EHRs in their offices, on the maternity wards and in the neonatal intensive care units as a test paradigm for this technology. The tools and methods we deliver should readily translate to other health care settings that collect behind-the-scenes electronic metadata such as audit trails. We believe that by applying the methods of social networking to define clinical relationships around a patient's care we will enable new areas of research into the usage of EHRs to promote patient safety and other improvements in care.

Trends in outpatient transthoracic echocardiography: impact of appropriateness criteria publication.

BACKGROUND: The impact of the 2007 American College of Cardiology Foundation Transthoracic Echocardiography Appropriateness Criteria on trends in appropriateness is unknown. Therefore, we sought to identify the appropriateness of outpatient transthoracic echocardiography pre- and postpublication of this document. METHODS: The 2007 Appropriateness Criteria were used to classify outpatient echocardiographic studies at an academic medical center during October 2000 and October 2008. The patient's electronic medical record was used to identify echocardiographic indication and appropriateness. RESULTS: From October 2000 to October 2008, there was an 85% increase in outpatient echocardiographic volume. Using the Appropriateness Criteria, there was no significant change in inappropriate referrals (13% and 15%, P=.58). Sixty-five studies (12%) were referred for indications "not addressed" by the document, with an increase (7% to 15%, P=.012) from 2000 to 2008. In a second analysis, incorporating the 2008 Valve Guidelines, an increase was demonstrated in the total number of studies that could be classified, but there was no significant change in the proportion of inappropriate referrals (P=.50). There remained a significant increase (3% to 10%, P=.009) in the proportion of indications "not addressed" by either guideline. CONCLUSION: From October 2000 to October 2008, we experienced a near doubling of outpatient echocardiographic volume, with no significant change in the percent of inappropriate referrals despite interim publication of the Appropriateness Criteria document. In addition, there was an increase in echocardiographic referrals for "not addressed" indications. Future efforts are needed both to refine the Appropriateness Criteria to include unaddressed indications and to promote its effective implementation.