In an effort to ensure the unnecessary use of cardiac ultrasound imaging, the American College of Cardiology Foundation and the American Society of Echocardiography, in collaboration with other interested professional societies, have released a set of "Appropriateness Criteria" for two of the most commonly used cardiac ultrasound techniques - transthoracic (TTE) and transesophageal (TEE) echocardiography (see: Appropriateness Criteria For Performance Of Cardiac Ultrasound Exams Released). Below is an excerpt from the announcement:
The TTE/TEE Appropriateness Criteria review common scenarios found in clinical practice and address the appropriateness of ordering echocardiograms for each situation. The Criteria address a broad range of clinical situations in which TTE/TEE might be used, such as for patients presenting with signs and symptoms that could represent heart disease, like murmurs and palpitations, and conditions such as hypertension, stroke, heart valve disease, and suspected or known congenital heart disease....The Appropriateness Criteria for TTE/TEE should help guide physicians in determining when and how often to use the tests. In general, use of TTE/TEE for the initial evaluation of structure and function was viewed favorably, while routine repeat testing and general screening uses in certain clinical scenarios were viewed less favorably. The new criteria will increase physicians' confidence that they are ordering an echocardiogram for the appropriate reasons, and help to educate them about when the test may not be necessary.
It appears to me that medical societies have a penchant for developing and publishing such appropriateness criteria that are applicable to various aspects of healthcare delivery. And, in fact, the physicians comprising these organizations are uniquely qualified to develop such criteria because, as in the case described above, they deliver the services in question. The pursuit of such projects, in fact, might appear counter-intuitive because the practitioners themselves might suffer economically if adherence to the criteria resulted in a decrease in the number of studies ordered.
However, after developing such criteria, the societies then have bragging rights for having taken constructive measures in fostering appropriate healthcare delivery and thereby lowering the cost of healthcare by reducing the demand for unnecessary services. The article predicts that the availability of these criteria "will increase physicians' confidence" that they are now ordering the procedures in an appropriate manner.
I am going to go way out on a limb here and suggest that the vast majority of clinicians ordering TTE and TEE echocardiography will never have heard about these criteria or much less have the opportunity to be educated by them. Thinking in simplistic terms, I believe that most clinicians are motivated by three factors when ordering diagnostic studies for their patients: (1) the most efficient use of their time; (2) arriving at the correct diagnosis; and (3) achieving patient satisfaction for their efforts. Put another way, I believe that clinicians are more concerned about "doing things right" than "doing the right things" because of our reimbursement system.
If my understanding of the mind of clinicians is correct, my personal suggestion to professional societies is that the development of "appropriateness criteria" will have little impact on physician behavior. A preferable approach, I believe, would be to turn to the development of workflow diagrams to advise clinicians about how to most efficiently arrive at a diagnosis for various medical conditions. In this way, they will quickly command the attention and admiration of clinicians for whom practice efficiency gains are a major driver. Arriving at the correct diagnosis more efficiently and rapidly will also surely increase patient satisfaction.
