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Comment on “Appropriate use criteria for transthoracic echocardiography at a tertiary care center”Comment on “Appropriate use criteria for transthoracic echocardiography at a tertiary care center”
Comentário a critérios de adequação para ecocardiografia transtorácica num centro terciário
Ana Galrinho
Serviço de Cardiologia, CHLC-Hospital de Santa Marta, Lisboa, Portugal
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"afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, CHLC-Hospital de Santa Marta, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Comentário a critérios de adequação para ecocardiografia transtorácica num centro terciário" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2139 "Ancho" => 3257 "Tamanyo" => 847111 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">American College of Cardiology recommendations on the Choosing Wisely website.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the last ten years there have been considerable improvements in imaging techniques in various areas and in cardiovascular imaging in particular. These advances have made diagnosis easier, but have also led to a dramatic increase in the use of diagnostic exams and hence a significant increase in health costs. In the USA, Medicare spending on diagnostic tests more than doubled between 2000 and 2006, while expenditure in the area of cardiology rose from $1.6 billion to $5.1 billion in 2006.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,2</span></a> These figures are giving rise to increasing concerns about the economic implications of this exponential growth, which will rapidly become financially and socially unsustainable. Reviews in the field of health economics show that the use of computed tomography (CT) increased three-fold, magnetic resonance imaging (MRI) four-fold and ultrasound imaging by 70% between 1996 and 2010, while nuclear medicine studies decreased by a third from 2008 onward, possibly due to the increasing popularity of other techniques such as coronary CT angiography.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The explosion in costs between 2000 and 2006 and its economic impact have been the subject of several studies that sought to determine the reasons behind this situation and to try and find a solution.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Among the causes of most often put forward for these spiraling costs are the greater diagnostic ability of the new imaging techniques and their novelty value, patients’ growing awareness and demand for objective exams, fragmentation of care with duplication of testing, the practice of ‘defensive medicine’ and physicians’ lack of confidence in clinical assessment leading to a perceived need for confirmation from imaging studies, financial incentives for referring physicians, and demographic factors, especially aging populations.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5–8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These studies focus on the USA and may not be directly applicable to other countries with different healthcare systems. However, certain factors merit further consideration, including the incessant need to confirm diagnoses as part of the growing practice of ‘defensive medicine’ based on intensive imaging, often the result of pressure from patients who have increasing access to online information (“Dr. Google”), wide media coverage of health-related subjects in recent years, and the growing number of medical malpractice lawsuits, especially in the USA. A 2008 study by the Massachusetts Medical Society showed that 22% of X-rays, 28% of CT scans, 27% of MRIs and 24% of ultrasound studies were performed for ‘defensive’ reasons.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">All of these factors explain why, according to one study, 20%–50% of advanced diagnostic imaging tests are of little or no benefit to the patient.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In view of the need to rein in this growth by imposing limits, from both financial and medical standpoints, it became clear that appropriate use criteria were needed in order to provide some guidance to the medical community in terms of when to request diagnostic imaging studies.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,11</span></a> The intention was to avoid not only underutilization but also overutilization, which puts the patient at unnecessary risk, both directly by invasive techniques and indirectly due to radiation.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12–14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">An appropriate procedure was defined by Fitch et al. for the RAND Corporation as “one in which the expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost”,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> which can be summarized as “the right test for the right patient at the right time”.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Appropriate use criteria for echocardiography were published by the American College of Cardiology and the American Society of Echocardiography (ACC/ASE) in 2007<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> and revised in 2011.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> It should be borne in mind that these criteria were designed for the particular circumstances in the USA and have been adapted for use in other countries.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18,19</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI) are in the process of defining their own appropriate use criteria for echocardiography<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> that are suited to the European context<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> and that will weigh the costs and benefits of cardiovascular imaging in order to rationalize and optimize the available resources. Central to this process is the definition of what is and what is not appropriate, although there will be borderline cases that require further evidence before a decision is possible. The criteria will cover the following crucial points:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">the timing of initial and repeat tests for different conditions;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">prioritization of workload in imaging laboratories according to appropriate use criteria, improving scheduling and optimizing the organization of resources;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">standardization of results in order to avoid unnecessary repeat exams;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">control of costs and rationalization of resources.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">A recent review analyzing changes in appropriate use of noninvasive cardiovascular imaging revealed marked improvements in appropriateness resulting from new appropriate use criteria in transthoracic and transesophageal echocardiography and CT angiography but not in stress echocardiography.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The Choosing Wisely online campaign, launched in 2012 by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, has the goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. The ACC contributed four recommendations concerning cardiac imaging, including echocardiography.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23,24</span></a> These recommendations are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Little is known of the extent of this problem in Portugal, and so the study by Fonseca et al. in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> is a pioneering one. The authors reviewed requests for transthoracic echocardiographic exams over a randomly chosen period of one month in a tertiary care center.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study's main limitation is that it reports the situation in a tertiary center, which cannot be extrapolated to other cardiology departments.</p><p id="par0090" class="elsevierStylePara elsevierViewall">One important difference from other studies in the literature is that the proportion of inappropriate requests was higher among cardiologists than non-cardiologists. This may be due to the proximity of the echo lab and hence easy access for cardiologists; most exams (around 52%) were requested by cardiologists. The fact that experts in echocardiography were responsible for a similar percentage of inappropriate exams to less experienced cardiologists supports the idea that ease of access contributes to this finding.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In a single-center study by Ward et al. published in 2008, 89% of 1385 echocardiograms were considered appropriate and 11% inappropriate; only 40% of appropriate exams and 17% of inappropriate exams revealed new major echocardiographic abnormalities. Non-cardiac specialists ordered more inappropriate studies than cardiac specialists (13% vs. 9%, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In a study in Italy by Latanzi et al., the authors reviewed the indications for echocardiography in 2848 patients and concluded that about half of requests could be considered inappropriate, with 23.1% of non-cardiologists’ requests being inappropriate, 37% appropriate and 39.9% of doubtful appropriateness, as opposed to 11.4%, 58.8% and 29.8%, respectively, among cardiologists.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The fact that inappropriate exams were more common in outpatients than in inpatients in the study by Fonseca et al. is understandable, since hospitalization constitutes preselection of the patient.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Residents were slightly more likely than specialists to request inappropriate exams, which may be due to the practice of ‘defensive medicine’ and relative lack of experience, both factors mentioned in the literature.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">28,29</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Some echocardiographic exams were considered unclassifiable according to the 2011 ACC/ASE criteria, many of them before or after invasive procedures such as transcatheter aortic valve implantation or left atrial appendage closure, which are increasingly common and will be covered in future revisions of the criteria. The EACVI criteria are awaited.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Although the subject is not part of medical training, it is essential to teach the concept of appropriate use and to increase awareness of its importance,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> since only in this way can resources be optimized by avoiding unnecessary and expensive diagnostic exams that may carry risks for the patient and that consume time and resources with no apparent improvement in medical outcomes.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Galrinho A. Comentário a critérios de adequação para ecocardiografia transtorácica num centro terciário. Rev Port Cardiol. 2015;34:719–722.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2139 "Ancho" => 3257 "Tamanyo" => 847111 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">American College of Cardiology recommendations on the Choosing Wisely website.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolving trends in the use of echocardiography: a study of Medicare beneficiaries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.S. Pearlman" 1 => "T. Ryan" 2 => "M.H. Picard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2007.02.048" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2007" "volumen" => "49" "paginaInicial" => "2283" "paginaFinal" => "2291" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17560294" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0160" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI. 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.B. Mark" 1 => "J.L. Anderson" 2 => "J.A. Brinker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.02.002" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2014" "volumen" => "63" "paginaInicial" => "698" "paginaFinal" => "721" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24556329" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0165" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Report GAO-08-452" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Report to Congressional Requesters. Medicare Part B Imaging Services June 2008: Rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "United States Government Accountability Office" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2008" "editorial" => "U.S. Government Accountability Office" "editorialLocalizacion" => "Washington, DC" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0170" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The perfect storm of overutilization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.J. Emanuel" 1 => "V.R. Fuchs" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.299.23.2789" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2008" "volumen" => "299" "paginaInicial" => "2789" "paginaFinal" => "2791" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18560006" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0175" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The nuclear cardiology report: problems, predictors, and improvement. A report from the ICANL database" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.L. Tilkemeier" 1 => "E.R. Serber" 2 => "M.B. Farrell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12350-011-9390-z" "Revista" => array:6 [ "tituloSerie" => "J Nucl Cardiol" "fecha" => "2011" "volumen" => "18" "paginaInicial" => "858" "paginaFinal" => "868" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21681615" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0180" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rising use of diagnostic medical imaging in a large integrated health system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Smith-Bindman" 1 => "D.L. Miglioretti" 2 => "E.B. Larson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Health Aff (Millwood)" "fecha" => "2008" "volumen" => "27" "paginaInicial" => "1491" "paginaFinal" => "1502" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0185" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Financial incentives and the art of payment reform" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.K. Hollenbeck" 1 => "B.K. Nallamothu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2011.1630" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2011" "volumen" => "306" "paginaInicial" => "2028" "paginaFinal" => "2030" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22068998" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0190" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is there empirical evidence for “defensive medicine”? A reassessment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.A. Sloan" 1 => "J.H. Shadle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jhealeco.2008.12.006" "Revista" => array:6 [ "tituloSerie" => "J Health Econ" "fecha" => "2009" "volumen" => "28" "paginaInicial" => "481" "paginaFinal" => "491" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19201500" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0195" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of self-referral on utilization of advanced diagnostic imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.C. Levin" 1 => "V.M. Rao" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "2011" "volumen" => "196" "paginaInicial" => "848" "paginaFinal" => "852" "itemHostRev" => array:3 [ "pii" => "S0140673611619314" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0200" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACCF proposed method for evaluating the appropriateness of cardiovascular imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.R. Patel" 1 => "J.A. Spertus" 2 => "R.G. Brindis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2005.08.030" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2005" "volumen" => "46" "paginaInicial" => "1606" "paginaFinal" => "1613" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16226195" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0205" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The appropriateness imperative" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.F. Redberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2007.05.006" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2007" "volumen" => "154" "paginaInicial" => "201" "paginaFinal" => "202" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17643564" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0210" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.M. Bradley" 1 => "J.A. Spertus" 2 => "K.F. Kennedy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamainternmed.2014.3904" "Revista" => array:6 [ "tituloSerie" => "JAMA Intern Med" "fecha" => "2014" "volumen" => "174" "paginaInicial" => "1630" "paginaFinal" => "1639" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25156821" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0215" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Economic and biological costs of cardiac imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Picano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1476-7120-3-13" "Revista" => array:5 [ "tituloSerie" => "Cardiovasc Ultrasound" "fecha" => "2005" "volumen" => "3" "paginaInicial" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15916702" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0220" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac imaging: does radiation matter?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.J. Einstein" 1 => "J. Knuuti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehr281" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2012" "volumen" => "33" "paginaInicial" => "573" "paginaFinal" => "578" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21828062" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0225" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The RAND/UCLA Appropriateness Method User's Manual" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Fitch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2001" "editorial" => "RAND" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0230" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.S. Douglas" 1 => "B. Khandheria" 2 => "R.F. Stainback" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2007.05.003" "Revista" => array:7 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2007" "volumen" => "50" "paginaInicial" => "187" "paginaFinal" => "204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17616306" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0890856715000386" "estado" => "S300" "issn" => "08908567" ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0235" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does the revised appropriate use criteria for echocardiography represent an improvement over the initial criteria? A comparison between the 2011 and the 2007 appropriateness use criteria for echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.B. Parikh" 1 => "J. Asheld" 2 => "S. Kort" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2011.09.017" "Revista" => array:7 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2012" "volumen" => "25" "paginaInicial" => "228" "paginaFinal" => "233" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22014427" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022399911001930" "estado" => "S300" "issn" => "00223999" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0240" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.M. Gurzun" 1 => "A. Ionescu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ehjci/jet186" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J Cardiovasc Imaging" "fecha" => "2014" "volumen" => "15" "paginaInicial" => "450" "paginaFinal" => "455" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24154849" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0245" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appropriateness in echocardiography and clinical priority classification criteria: a proposal from the Italian Society of Cardiovascular Echography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Mandorla" 1 => "P. Trambaiolo" 2 => "M. De Cristofaro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "G Ital Cardiol" "fecha" => "2010" "volumen" => "11" "paginaInicial" => "503" "paginaFinal" => "533" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0250" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appropriateness criteria for cardiovascular imaging use in clinical practice: a position statement of the ESC/EACVI taskforce" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Garbi" 1 => "G. Habib" 2 => "S. Plein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ehjci/jeu031" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J Cardiovasc Imaging" "fecha" => "2014" "volumen" => "15" "paginaInicial" => "477" "paginaFinal" => "482" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24639554" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0255" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular imaging practice in Europe: a report from the European Association of Cardiovascular Imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Lancellotti" 1 => "E. Płońska-Gościniak" 2 => "M. Garbi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ehjci/jev116" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J Cardiovasc Imaging" "fecha" => "2015" "volumen" => "16" "paginaInicial" => "697" "paginaFinal" => "702" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25944050" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0260" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Temporal changes in appropriateness of cardiac imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Fonseca" 1 => "K. Negishi" 2 => "P. Otahal" 3 => "T.H. Marwick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2014.11.057" "Revista" => array:7 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "65" "paginaInicial" => "763" "paginaFinal" => "773" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25720619" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109707008303" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0265" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Choosing Wisely: Promoting conversations between providers and patients. Available from: <a href="http://www.choosingwisely.org/">www.choosingwisely.org</a>." ] ] ] 23 => array:3 [ "identificador" => "bib0270" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tests that may be overused or misused in cardiology: the Choosing Wisely campaign" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.A. Beller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12350-012-9569-y" "Revista" => array:6 [ "tituloSerie" => "J Nucl Cardiol" "fecha" => "2012" "volumen" => "19" "paginaInicial" => "401" "paginaFinal" => "403" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22547398" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0275" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[in press]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appropriate use criteria for transthoracic echocardiography at a tertiary care center" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Fonseca" 1 => "F. Sampaio" 2 => "J. Ribeiro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2015.06.010" "Revista" => array:3 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2015" "volumen" => "12" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0280" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective evaluation of the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography appropriateness criteria for transthoracic echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.P. Ward" 1 => "I.N. Mansour" 2 => "N. Lemieux" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcmg.2008.07.004" "Revista" => array:6 [ "tituloSerie" => "JACC Cardiovasc Imaging" "fecha" => "2008" "volumen" => "1" "paginaInicial" => "663" "paginaFinal" => "671" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19356497" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0285" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of the appropriateness of prescribing echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "F. Lattanzi" 1 => "M. Magnani" 2 => "L. Cortigiani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ital Heart J Suppl" "fecha" => "2002" "volumen" => "3" "paginaInicial" => "613" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12116810" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0290" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Educational intervention to reduce outpatient inappropriate echocardiograms: a randomized control trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.S. Bhatia" 1 => "D.M. Dudzinski" 2 => "R. Malhotra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Coll Cardiol Imaging" "fecha" => "2014" "volumen" => "7" "paginaInicial" => "857" "paginaFinal" => "866" ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0295" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Kossaify" 1 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 41 | 35 | 76 |
| 2024 September | 48 | 32 | 80 |
| 2024 August | 39 | 29 | 68 |
| 2024 July | 39 | 38 | 77 |
| 2024 June | 27 | 31 | 58 |
| 2024 May | 34 | 26 | 60 |
| 2024 April | 28 | 23 | 51 |
| 2024 March | 39 | 16 | 55 |
| 2024 February | 33 | 19 | 52 |
| 2024 January | 17 | 26 | 43 |
| 2023 December | 20 | 22 | 42 |
| 2023 November | 30 | 22 | 52 |
| 2023 October | 21 | 16 | 37 |
| 2023 September | 18 | 20 | 38 |
| 2023 August | 23 | 10 | 33 |
| 2023 July | 16 | 13 | 29 |
| 2023 June | 34 | 16 | 50 |
| 2023 May | 31 | 35 | 66 |
| 2023 April | 23 | 4 | 27 |
| 2023 March | 40 | 29 | 69 |
| 2023 February | 34 | 22 | 56 |
| 2023 January | 20 | 20 | 40 |
| 2022 December | 49 | 26 | 75 |
| 2022 November | 59 | 26 | 85 |
| 2022 October | 46 | 24 | 70 |
| 2022 September | 34 | 36 | 70 |
| 2022 August | 27 | 28 | 55 |
| 2022 July | 27 | 44 | 71 |
| 2022 June | 34 | 30 | 64 |
| 2022 May | 50 | 36 | 86 |
| 2022 April | 41 | 32 | 73 |
| 2022 March | 26 | 39 | 65 |
| 2022 February | 27 | 34 | 61 |
| 2022 January | 24 | 20 | 44 |
| 2021 December | 18 | 23 | 41 |
| 2021 November | 28 | 36 | 64 |
| 2021 October | 24 | 33 | 57 |
| 2021 September | 21 | 28 | 49 |
| 2021 August | 26 | 33 | 59 |
| 2021 July | 21 | 26 | 47 |
| 2021 June | 25 | 10 | 35 |
| 2021 May | 57 | 40 | 97 |
| 2021 April | 79 | 29 | 108 |
| 2021 March | 61 | 22 | 83 |
| 2021 February | 75 | 15 | 90 |
| 2021 January | 52 | 13 | 65 |
| 2020 December | 52 | 8 | 60 |
| 2020 November | 37 | 14 | 51 |
| 2020 October | 30 | 14 | 44 |
| 2020 September | 63 | 19 | 82 |
| 2020 August | 22 | 6 | 28 |
| 2020 July | 77 | 16 | 93 |
| 2020 June | 53 | 10 | 63 |
| 2020 May | 51 | 5 | 56 |
| 2020 April | 47 | 12 | 59 |
| 2020 March | 52 | 9 | 61 |
| 2020 February | 78 | 15 | 93 |
| 2020 January | 42 | 7 | 49 |
| 2019 December | 41 | 10 | 51 |
| 2019 November | 45 | 7 | 52 |
| 2019 October | 24 | 4 | 28 |
| 2019 September | 89 | 10 | 99 |
| 2019 August | 37 | 5 | 42 |
| 2019 July | 47 | 9 | 56 |
| 2019 June | 29 | 22 | 51 |
| 2019 May | 33 | 12 | 45 |
| 2019 April | 26 | 11 | 37 |
| 2019 March | 50 | 13 | 63 |
| 2019 February | 57 | 6 | 63 |
| 2019 January | 68 | 7 | 75 |
| 2018 December | 112 | 9 | 121 |
| 2018 November | 111 | 11 | 122 |
| 2018 October | 184 | 15 | 199 |
| 2018 September | 60 | 15 | 75 |
| 2018 August | 29 | 4 | 33 |
| 2018 July | 24 | 3 | 27 |
| 2018 June | 37 | 9 | 46 |
| 2018 May | 32 | 8 | 40 |
| 2018 April | 39 | 2 | 41 |
| 2018 March | 45 | 7 | 52 |
| 2018 February | 28 | 8 | 36 |
| 2018 January | 28 | 4 | 32 |
| 2017 December | 41 | 5 | 46 |
| 2017 November | 44 | 10 | 54 |
| 2017 October | 29 | 12 | 41 |
| 2017 September | 23 | 6 | 29 |
| 2017 August | 30 | 14 | 44 |
| 2017 July | 21 | 9 | 30 |
| 2017 June | 39 | 7 | 46 |
| 2017 May | 28 | 7 | 35 |
| 2017 April | 11 | 8 | 19 |
| 2017 March | 20 | 27 | 47 |
| 2017 February | 28 | 4 | 32 |
| 2017 January | 37 | 1 | 38 |
| 2016 December | 32 | 9 | 41 |
| 2016 November | 34 | 6 | 40 |
| 2016 October | 45 | 6 | 51 |
| 2016 September | 38 | 2 | 40 |
| 2016 August | 15 | 1 | 16 |
| 2016 July | 16 | 6 | 22 |
| 2016 June | 8 | 6 | 14 |
| 2016 May | 17 | 3 | 20 |
| 2016 April | 37 | 18 | 55 |
| 2016 March | 28 | 18 | 46 |
| 2016 February | 45 | 38 | 83 |
| 2016 January | 104 | 43 | 147 |
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