CLINICAL AUDIT OF ECHOCARDIOGRAPHY SERVICES UTILIZATION AT ECHOCARDIOGRAPHY SUITE, UNIVERSITY COLLEGE HOSPITAL, IBADAN

Abstract

Cardiovascular diseases are the major cause of death worldwide. Since its discovery in the 20th century, echocardiography(ECHO) has become one of the pivotal tools in assessing the structural and functional characteristics of the heart. With the increase in requests and demand for ECHO, there has risen an unwanted problem- inappropriate requests for ECHO. There has therefore arisen the need to audit ECHO labs for the appropriateness of ECHO requests. The study was a descriptive, cross sectional study involving a review of the records of all requests and services provided by the unit in the past sixteen months. The patients referred from the · out- patient clinics and in-patient wards for echocardiography (ECHO) from 1st of June, 2015 till 30th of September, 2016 were collated and analysed for patterns of referral as well as the indications for echocardiography. Eligible participants in the study were people referred for ECHO to the ECHO suite of University College Hospital, Ibadan. They consisted of male and female adults aged 18 years and above. The ejection fractions (EF) of the various groups were evaluated and analysed. Other measures of cardiac chamber dimension and function were also assessed. Principal exposure variables are echocardiography assessment and the indications for echocardiography. The outcome variables are categories of appropriateness of echocardiography which are appropriate, inappropriate and uncertain. Other outcome variables include echocardiography findings which are categorized into normal and abnormal findings, preserved or reduced left ventricular ejection fraction (LVEF). A total of 2174 ECHOs were done during the period of review. The most common indication was hypertension (16%), closely followed by hypertensive heart disease (12.4%). Other major indications were symptoms and signs suggestive of cardiovascular disease, imaging evidence of possible cardiac disease, pre- surgical assessment of patients and peri-chemotherapy assessment of the heart. The percentage of appropriate, inappropriate and uncertain indications according to the 2011 appropriate use criteria for trans thoracic echocardiography were 41.4%, 31.1% and 0.1% respectively. Less than ten percent (9.3%) of the indications could not be classified by the 2011 AUC while 18.1 % of the ECHOs had no indication. All classifications of the indications had normal findings, with appropriate, inappropriate and unclassified having 23.6%, 24% and 27.9% respectively. Those with abnormal findings in the appropriate group had unduly elevated blood pressure, left atrial dilatation and reduced ejection fraction. However, those with the inappropriate group had no significant difference in the LVEF while in the unclassified group, the left atrial diameter and systolic blood pressure was not significantly different. The percentage of appropriate indications was low in this study as compared to others, largely because the most common indication was inappropriate and over 18% of the studies had no indications. The appropriate indications seemed to have a superior discriminant ability as compared to the other classes of indications as those with abnormal findings tended to have features both of diastolic and systolic dysfunction. There is a need to ensure appropriate indications are filled for ECHO request forms. The 2011 AUC guideline may also be review to expand the uncertain group of indications.