Title : A single-centre study for assessing and improving appropriateness of rejected transthoracic echocardiography requests and correlation with British Society of Echocardiography published clinical indications
Abstract:
Introduction: Transthoracic echocardiography (TTE) is an indispensable non-invasive cardiac imaging modality that is widely utilised forming a crucial part of patients’ care pathway throughout clinical practice. The rising prevalence of cardiovascular diseases has resulted in an increased burden on TTE services which has shown a meteoric surge of 5.7% per annum between 2014 and 2019 resulting in a breach of the 6-week maximum diagnostic wait policy. This demand-supply mismatch is further compounded by inappropriate TTE requests which lead to eventual difficulties in triaging resulting in cancellation. To standardise the triage system and better define indications of TTE, the British Society of Echocardiography (BSE) has released a set of guidelines.
Purpose: The aim of our study was to determine the appropriateness of TTE requests and to evaluate factors responsible for rejection, devise interventions to improve acceptance rates, and evaluate their effectiveness. We further assessed perception and knowledge among requesting clinicians regarding rejected requests.
Methods: A retrospective analysis was conducted of all rejected TTE requests in a tertiary care Cardiology- Unit for the months of January-September,2023. The rejected requests of the initial study period (January- February,23) were sub-categorised into in-patient vs out-patient, site-specific and requesting specialty- specific cohorts and compared based on reasons of rejection and BSE guidelines specified indications. An anonymous survey was also conducted among requesting clinicians. The dataset was analysed to identify areas of improvement, and 3 interventions were designed and implemented to improve acceptance rates: educational sessions with dissemination of BSE guidelines, TTE requesting memory aids and greater access to community performed TTE reports to avoid duplication.
Results: 455 TTE requests were rejected in the initial 2 months trust-wide - majority of them (71.6%) were for in-patient admissions. Cardiology (173) and Respiratory Medicine (67) were the leading specialties with rejected requests - possibly a reflection of their admitted patient cohort requiring cardiac imaging more frequently. Insufficient clinical information and duplicate scan (in community/recent admission) contributed predominantly as the reasons for rejection at 36.1% and 20% respectively. Suspected heart failure, suspicion of acute mechanical valvular pathology and assessment of left ventricular function were the 3 leading indications of rejected TTE requests according to BSE guidelines. A large proportion of survey responders (72.8%) felt they were assigned responsibility to request an echo for a patient they have limited knowledge about - most of them being junior clinicians(grade<ST3). The popularity of BSE guidelines remained low with 79.6% of the responders remaining unaware of them. Half of the senior clinicians/responders did not access to community-performed TTE reports. Lack of adequate clinical information was identified as the primary reason of rejection in other similar studies as well, but promoting awareness about TTE indications and BSE guidelines improved rejection rates. In our study, a transient improvement was noted in rejection rates only restricted to the acute-cardiology- take-area in the immediate post-intervention period, however it was not statistically significant or sustained.
Conclusions: The study highlights the importance of a standardised guideline-centric framework for requesting TTEs to streamline service provision and reduce diagnostic delays thereby improving patient care.
