Echocardiography Diagnostic Accuracy

Transcription

1 Echcardigraphy Diagnstic Accuracy Measure Descriptin: The prprtin f ptentially preventable and clinically imprtant inaccurate diagnses amng cngenital heart surgical patients. Numeratr Number f cngenital heart surgeries with ne r mre clinically imprtant inaccurate preperative echcardigraphic diagnses 2 (mderate clinical impact r greater 3 ) that are pssibly preventable 4 r preventable 4 determined within 15 days after surgical prcedure. Denminatr Number f cngenital heart surgical patient wh underwent preperative echcardigraphy during the measurement perid Denminatr Exclusins Denminatr Exceptins Definitins/Ntes Nne Nn-primary cardiac peratin preperative echcardigrams (e.g. sternal clsure r wire remval r cannulatin/decannulatin fr extracrpreal supprt), preperative studies perfrmed frm utside echcardigraphy labratries. 1. Preperative echcardigram: The echcardigram r echcardigraphy reprt that is primarily used fr surgical planning r echcardigram reprt that includes the cmplete anatmic elements used fr surgical planning. 2. Inaccurate Diagnses: are defined as diagnses that are unintentinally delayed, wrng r missed as judged frm eventual appreciatin f the existing data r f mre definitive infrmatin. 3. Clinical Impact Clinical Impact Clinical Crrelate Example Minr Mderate N change in patient management r clinical curse; n adverse utcme Alteratin in patient management r clinical curse withut adverse patient event Undiagnsed left superir vena cava t intact crnary sinus discvered intra-peratively in patient underging surgery fr patent ductus arterisus ligatin Undiagnsed patent ductus arterisus but clsed at surgery in patient underging ventricular septal defect clsure Severe 4. Preventability Adverse event cntributing t patient injury; r errr cntributing t the perfrmance f an unnecessary/additinal invasive prcedure; r errr that cntributed t patient demise Inaccurate diagnsis f atrial septal defect cntributing t perfrmance f unnecessary cardiac surgery; Missed diagnsis f anmalus rigin f left crnary artery cntributing t a mycardial infarctin and death 1

2 Preventability Definitin Example Preventable Pssibly preventable Nt preventable Errr is preventable if accurate diagnsis is expected by the available images, imaging mdality and/r imaging cnditins (i.e. the diagnsis is readily apparent n study images but is nt reprted) Pssibly preventable if an accurate diagnsis may be expected by echcardigraphy and/r imaging cnditins but may have required a reasnably different technique such as cmplete anatmic sweep r use f clr Dppler Accurate diagnsis is nt pssible if the images, imaging mdality, r imaging cnditins d nt permit diagnsis An echcardigram image clearly demnstrates a patent ductus arterisus by 2D and clr Dppler but the study is interpreted as n patent ductus arterisus Failing t diagnse an artpulmnary windw due t incmplete 2D and lack f clr Dppler interrgatin f the arta and pulmnary artery Failure t image a ligamentum arterisum cntributing t a vascular ring r failure t diagnse crnary artery anmaly by transthracic echcardigram during active CPR Measurement Perid Surces f Data Quarterly Preperative echcardigraphic findings/reprt will be cmpared t findings frm ther tests (e.g., cardiac catheterizatin, cardiac magnetic resnance imaging, cardiac cmputed tmgraphy), perative bservatins, subsequent echcardigraphic examinatins, autpsy and utpatient clinic recrds up t 14 days* fllwing the date f the cardiac surgery. Data regarding presence f diagnstic errr, severity and cntributrs as learned frm quality imprvement meetings can be anther surce. *time frame can be limited t duratin f admissin The recmmended ptimal apprach is that if an inaccurate diagnsis is determined t be present, the categrizatin f clinical impact (severity) and preventability will take place during each echcardigraphy labratries quality meeting Attributin Care Setting The echcardigraphy labratry wuld cllect, review, categrize and reprt their wn data internally. Outpatient r inpatient Ratinale Quality in diagnstic imaging is critically related t diagnstic accuracy. 2

3 Inaccurate imaging findings may adversely impact patient safety and/r alter patient management. Quality review is required f echcardigraphy labratries fr accreditatin. Patient risk factrs fr diagnstic errr include weight < 5 Kg, mderate r cmplex anatmy, uncmmn heart disease. Situatinal risk factrs include echcardigrams perfrmed and interpreted vernight and during weekends and unsedated children <36 mnths. Cmmn anatmic features invlved with diagnstic errr include crnary arteries, artic arch/branching and pulmnary veins. ACC/AHA guidelines Clinical Recmmendatin(s) Spertus JA, et al; ACCF/AHA Task Frce n Perfrmance Measures. ACCF/AHA new insights int the methdlgy f perfrmance measurement: a reprt f the American Cllege f Cardilgy Fundatin/American Heart Assciatin Task Frce n perfrmance measures. J Am Cll Cardil Nv 16;56(21): Other guidelines: Benavidez OJ, Gauvreau K, Jenkins KJ, Geva T. Diagnstic errrs in pediatric echcardigraphy: develpment f taxnmy and identificatin f risk factrs. Circulatin Jun 10;117(23): Stern KW, Gauvreau K, Geva T, Benavidez OJ. The impact f prcedural sedatin n diagnstic errrs in pediatric echcardigraphy. J Am Sc Echcardigr Sep; 27(9): Benavidez OJ, Gauvreau K, Geva T. Diagnstic errrs in cngenital echcardigraphy: imprtance f study cnditins. J Am Sc Echcardigr Jun; 27(6): Challenges t Implementatin 1. Data cllectin and re-review f images requires time 2. Adjudicatin f discrepancy f imaging findings and ther data will need t be fairly determined during QI meetings 3. This metric is nt useful fr centers that d nt perfrm cardiac surgery Authrs This metric develpment was an effrt f the ACPC Sectin s Quality Metrics Wrk Grup led by Le Lpez, M.D., F.A.C.C. The Cllege is grateful fr the cntributins f the fllwing authrs: Oscar Benavidez, M.D. Massachusetts General Hspital Ann Kavanaugh-McHugh, M.D., F.A.C.C. Vanderbilt Children s Hspital Jhn Kvalchin, M.D., F.A.C.C. The Heart Center Natinwide Children s Hspital Philip Spevak, M.D., F.A.C.C. Jhn s Hpkins Hspital Le Lpez, M.D, F.A.C.C. Nicklaus Children s Hspital Pei-Ni Jne, M.D., F.A.C.C. Children s Hspital Clrad 3

4 Appendix: Case Review Prcess (Figure 1) This quality imprvement activity will invlve preperative echcardigrams frm patients presenting fr cngenital heart surgery. Data Cllectin Strategies Full Review: 100% f cardiac surgical cases Sample Review: 20 cnsecutive surgical cases with preperative echcardigrams perfrmed at the participating labratry reviewed quarterly (100 cases annually) Surgical cases under review wuld be entered int a Nn-Invasive Quality Imprvement Database (NIQID) r spreadsheet (Figure 2) Secndary case review f the preperative echcardigraphic images fr patients presenting fr cngenital heart surgery. Staff cardilgists/cardilgy fellws/trained sngraphers frm the echcardigraphy grup will perfrm this review. The preperative echcardigraphic findings will be cmpared t findings frm ther tests (e.g., cardiac catheterizatin, cardiac magnetic resnance imaging, and cardiac cmputed tmgraphy), intraperative bservatins, subsequent echcardigraphic examinatins, and autpsy and utpatient clinic recrds up t 15 days fllwing the date f the cardiac surgery. In many centers the preperative echcardigrams underg a secndary review prir t a child having cardiac surgery A case suspected f having an inaccurate diagnsis (candidate cases) wuld be identified and nted in the a Nn-Invasive Quality Imprvement Database r spreadsheet Amng the candidate cases, the relevant clinical and image data related t the inaccurate diagnsis will be presented at a mnthly Nn-Invasive Quality Imprvement Seminar A cnsensus based review f the case and the ensuing discussin will be used t finalize categrizatin f the inaccurate diagnsis type, severity, preventability and cntributr. (Benavidez, et al. Circulatin 2008) Surgical cases under review with a minimum dataset wuld be entered int a Nn-Invasive Quality Imprvement Database r spreadsheet Reprting Strategies Minimal data set includes age, initial diagnsis, presence f diagnstic errr, anatmic segment f diagnstic errr, final diagnsis, clinical impact, preventability and primary cntributr The finalized categrizatin will be entered int NIQID Diagnstic Errr Rate: Ttal number f preperative cases with clinically imprtant, ptentially preventable diagnstic errrs ver the ttal number f preperative echcardigrams Diagnstic Accuracy Rate: Ttal number f preperative cases with accurate diagnses ver the ttal number f preperative echcardigrams 4

5 Clinical Events 15 days pstcngenital heart surgery Ø Surveillance Events Case review Secndary image review: Cmparisn f pre-perative echcardigram findings t: Pre-perative cardiac catheterizatin Pre-perative cardiac MRI Operative inspectin Pst-perative echcardigrams/imaging Inaccurate Diagnsis Accurate Diagnsis Cnsensus based case discussin and categrizatin Data entry int Nn- Invasive Quality Imprvement frm Figure 1: Diagnstic Accuracy case identificatin and categrizatin prcess 5

6 Figure 2. Example spreadsheet minimal dataset Patient Age Initial diagnsis Accurate Diagnsis? Final diagnsis Methd f discvery Clinical impact Preventability Cntributr JJ1/1/ year Nrmal N Carctatin Review f echcardigram Mderate Preventable Misidentificatin f study images AB 2/2/ year secundum N secundum and muscular VSD Subsequent echcardigram Minr Pssibly preventable Incmplete examinatin f the ventricular septum DC 3/1/ years primum and cleft mitral valve Yes primum and cleft mitral valve