[The "Appropriatezza ECO Milano" project. Assessment of appropriateness of indications, prescriptions and clinical utility of two-dimensional Doppler echocardiography among inpatients and outpatients of Milan, Italy]

Antonio Mantero, Francesco Gentile, Antonia Alberti, Chiara Bencini, Amedeo Bongarzoni, Renato Bragato, Giovanna Branzi, Franco Casazza, Alessandro Cialfi, Livia Dihel, Erminia Giagnoni, Joanna Heyman, Leonida Lombardi, Roberto Mattioli, Anna Alice Mazzola, Vincenzo Montericcio, Mauro Pepi, Maurizio Tusa, Alberto Morabito
Giornale Italiano di Cardiologia 2008, 9 (12): 844-52

BACKGROUND: The value of echocardiography in the diagnosis and follow-up of most cardiovascular diseases is well established, even though the ever-increasing demand for the use of this technique is not always justifiable. The "Appropriatezza ECO Milano" project was developed among hospitals in Milan (Italy) to foster a rational use of echocardiography. The aim of this study was to evaluate and improve appropriateness of requests for two-dimensional color Doppler echocardiography, considering indications, prescription behaviors and clinical utility in both the outpatient and inpatient settings.

METHODS: Following several meetings, a consensus was reached whereby a multicenter, observational study would be undertaken. We assessed the value of each request in agreement with the 2003 American College of Cardiology/American Heart Association/American Society of Echocardiography guidelines. An ad hoc Microsoft Access database was developed to collect study data, which refer to May 2007. Eleven hospitals participated in the study.

RESULTS: 4130 echocardiographic examinations were considered (2300 performed in men and 1830 performed in women; mean age 64 +/- 16 years); 1701 examinations were performed in hospitalized patients and 2429 in outpatients. The incidence of pathological findings was higher in hospitalized patients (73%) than in outpatients (53%) (Pearson chi2 = 29, p<0.001). A higher additional clinical value was found in hospitalized vs non-hospitalized patients (48 vs. 35%, Pearson chi2 = 99; p <0.001). In both settings, the majority of echocardiographic examinations were requested by cardiologists (inpatients 36%, outpatients 54%). The most appropriate examinations were performed more frequently in class I or class IIA hospitalized patients (73%) than in outpatients (52%) (Pearson chi2 = 277, p<0.001). Furthermore, the least accurate the indication, the less the clinical utility found in examinations requested from hospitals and outpatient clinics (64 vs 61% in class I patients, Pearson chi2 = 413, p<0.001; 5 vs 11% in class III patients, Pearson chi2 = 584, p<0.001). Conclusions. Our data confirm an inadequate level of appropriateness of requests for two-dimensional color Doppler examinations in either inpatients or outpatients. After over 10 years of passively observing and recording this trend, a timely resolution of these issues is topical in order to improve the implementation of criteria and to guarantee cost-effective and high-quality cardiovascular care.

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