Evaluation of Appropriate Use of Preoperative Echocardiography Before Major Abdominal Surgery

A Retrospective Cohort Study

Allyson Tank, M.D.; Robert Hughey, M.D.; R. Parker Ward, M.D.; Peter Nagele, M.D., M.Sc.; Daniel S. Rubin, M.D., M.S.

Disclosures

Anesthesiology. 2021;135(5):854-863. 

In This Article

Results

Patient Characteristics

The study cohort consisted of 230,535 reports of patients, and characteristics of these patients are presented in Table 1. Overall, 13,936 reports of patients (6%) included a preoperative resting echocardiogram in the 60 days before a major abdominal surgical procedure. Patients who underwent preoperative resting echocardiography were older, with a mean age of 63 yr (SD = 14 yr) as compared to 57 yr (SD = 14 yr) in the untested cohort (P < 0.001). Patients who received a preoperative resting echocardiogram had higher frequencies of multiple comorbidities, including insulin-dependent diabetes mellitus, stroke, chronic kidney disease, coronary artery disease, heart failure, and any cardiac valve pathology (P < 0.001). We did not identify a difference between the cohorts in frequency of nonpreoperative resting echocardiography (1,502 of 13,936, 11% vs. 24,284 of 216,599, 11%; P = 0.115) in the year before the procedure. The untested cohort did have a higher frequency of other nonpreoperative cardiac tests performed in the year before surgery (1,119 of 13,936, 8% vs. 18,983 of 216,599, 9%; P = 0.002); however, this difference is unlikely to be clinically significant.

Classification According to the Appropriate use Criteria for Echocardiography

Characteristics of patients who underwent preoperative resting echocardiography for "appropriate," "rarely appropriate," and "unclassifiable" indications are presented in Table 2. Of all preoperative resting echocardiograms, 12,638 (91%) were classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Of classifiable studies, 8,959 (71%) were classified as "appropriate," and 3,679 (29%) were classified as "rarely appropriate." There was no change in the frequency of "appropriate" versus "rarely appropriate" echocardiograms that were classifiable by the Appropriate Use Criteria or Echocardiography throughout the study period (Supplemental Digital Content table 6, https://links.lww.com/ALN/C688). Repeat echocardiograms (i.e., a preoperative resting echocardiogram when another resting echocardiogram was done within the year before the procedure) accounted for 11% (1,502 of 13,936) of all perioperative resting echocardiograms, and 52% (785 of 1,502) were classified as "rarely appropriate," 36% (537 of 1,502) as "appropriate," and 12% (180 of 1,502) as "unclassifiable." Men had a higher proportion of "rarely appropriate" echocardiograms (2,031 of 6,308, 32% vs. 1,648 of 6,330, 26%; P < 0.001) as compared to women. Patients with coronary artery disease had the highest frequency (44%, 1,458 of 3,281) of "rarely appropriate" echocardiograms among all the cardiac comorbidities. The most common "rarely appropriate" echocardiogram indications in our study were surveillance of chronic ischemic heart disease (954 of 3,679, 26%), general preoperative examination (767 of 3,679, 21%), and hypertension (634 of 3,679, 17%).

Major Adverse Cardiac Events

The overall frequency of major adverse cardiac events that included myocardial infarction, cardiac arrest, and heart failure was 0.6% (1,317 of 230,535). The frequency among patients that did not have a preoperative echocardiogram was 0.5% (1,116 of 216,599) as compared to 1.4% (201 of 13,936) in patients who did receive a preoperative echocardiogram (P < 0.001). There was no difference in the frequency of major adverse cardiac events in patients with a "rarely appropriate" (1.8%, 66 of 3,679), "appropriate" (1.3%, 116 of 8,959), or "unclassifiable" resting echocardiogram (1.5%, 19 of 1,298; P = 0.086).

Sensitivity Analysis

In our cohort, 11.2% (25,786 of 230,535) of patient records contained a claim for a resting echocardiograms performed before the preoperative period. Of those echocardiograms, 23,160 (90%) were classifiable by the Appropriate Use Criteria for Echocardiography, 17,213 (74%) were "appropriate," and 5,947 (26%) were "rarely appropriate." The proportion of resting echocardiograms that were classified as "rarely appropriate" in the preoperative setting was higher than those outside of the preoperative period in our cohort. Additionally, the frequency for all resting echocardiograms done in the year before surgery can be seen in Supplemental Digital Content figure 1 (https://links.lww.com/ALN/C688) and Supplemental Digital Content table 7 (https://links.lww.com/ALN/C688). Resting echocardiograms in the 2 months before surgery accounted for 47% (28,122 of 59,788) of the total volume of resting echocardiograms. We observed a sharp increase in the frequency of resting echocardiograms in the 2 months before major abdominal surgery, as illustrated by Supplemental Digital Content figure 1 (https://links.lww.com/ALN/C688).

Among records of patients that included a resting echocardiogram in the preoperative period and also an echocardiogram in the previous year, mean Elixhauser comorbidity scores were greater for patients who had an "unclassifiable" 13 (SD = 11) and "appropriate" 12 (SD = 10) resting echocardiogram as compared to a "rarely appropriate" 10 (SD = 10) resting echocardiogram (P < 0.001). The frequency of myocardial infarction, cardiac arrest, and heart failure associated with repeat echocardiograms overall was 2.7% (39 of 1,502). There was no difference in the frequency of complications in patients with a "rarely appropriate" (3.3%, 26 of 785), "appropriate" (1.9%, 10 of 537), or "unclassifiable" resting echocardiogram (1.5%, 3 of 180; P = 0.187).

processing....