Point-of-Service Questionnaire identifies rarely appropriate and low-risk outpatient echocardiography requests: a prospective 1-year outcomes study
K Divekar, H Williams, H Abdelgawad, E McPhail, N Jahagirdar, E Denman, P Pearson, A Papachristidis, G Amin Youssef, T Marwick, M EskandariAbstract
Background
Avoidable cardiac events can occur when decision-making is delayed by waiting lists for transthoracic echocardiography (TTE). Prioritisation of Appropriate (A) indications could reduce these delays, but clinicians worry that cancelling Rarely Appropriate (RA) tests may compromise clinical safety. A four-question screening tool Point-of-Service Questionnaire (PSQ); 1. Absence of new cardiovascular symptoms; 2. routine surveillance indication; 3. prior TTE within 1 year; 4. Suspected endocarditis without clinical criteria has been proposed to identify RA indications but requires prospective outcomes validation.
Purpose
To evaluate 12-month cardiovascular outcomes in outpatient TTE waiting lists, based on appropriateness judged by PSQ.
Methods
The PSQ was prospectively applied to 2,036 consecutive requests on the outpatient TTE wait list. Requests with no or 1 affirmative response were flagged as Appropriate. Those with 2 or more responses were reviewed against Appropriate Use Criteria and relevant contemporary specialist guidelines and classified as possibly appropriate (PA) if TTE remained indicated, or RA if not. One-year outcomes were assessed using a predefined Cardiovascular Deterioration Composite (CDC) comprising all-cause death, myocardial infarction, stroke/transient ischaemic attack, arrhythmia-related hospitalisation, heart failure admission, or urgent unplanned cardiac intervention. Events were adjudicated for relationship to the original surveillance indication.
Results
PSQ flagged 646/2,036 (31.7%) requests; following specialist guideline review, 220 requests were classified as RA, while 426 were deemed PA based on specialist indications not captured by the PSQ. At 12 months, CDC events occurred in 0/220 (0%) RA, 9/426 (1.4%) PA and 58/1,390 (4.2%) of A patients (relative risk 0.33, 95% confidence interval 0.17–0.67; unadjusted). Only 1 of the 9 events in the PA group (0.15% of PSQ-flagged patients) was adjudicated as related to the underlying condition.
Conclusion
In this prospective cohort, PSQ-based screening was not associated with evidence of excess short-term adverse outcomes. Although specialist guideline review reduced the number classified as rarely appropriate, clinically significant events within the PSQ-flagged group were uncommon and rarely related to the underlying indication. These findings support further evaluation of prioritisation strategies for echocardiography.Fig 1- Methadology and findingsFig 2- PSQ flagged request outcomes review