From the perspective of a geriatric patient with a hip fracture, having a preoperative echocardiogram may not seem like a big deal, especially since it’s a noninvasive test. However, as Adair et al. reveal in an April 19, 2017 JBJS study, following clinical guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA) could have prevented “cardiac echoes” from being done in 34% of 100 elderly hip fracture patients without missing any disease. Such unnecessary testing not only adds cost to the health care system, but can also delay surgical treatment for an operation that evidence suggests is best performed within 24 to 48 hours.
A single reviewer blinded to the later results of the tests assessed whether the ACC/AHA guidelines were followed in each case of an ordered echo; when ≥1 of the criteria were met, the echo was considered ordered in accordance with the guidelines. The rate of adherence to the guidelines was 66% over the 3.5-year study period. No important heart disease was found in any of the 34 patients who underwent an echocardiogram that had not been indicated by the guideline criteria, and 14 of the 66 patients (21%) for whom an echo was indicated by the criteria were found to have heart conditions serious enough to modify anesthesia or medical management.
The most common documented reasons for ordering an echo outside the guideline criteria were dementia that prevented evaluation of preoperative cardiac condition and generic “evaluation of cardiac function,” even though those patients had no history, physical exam findings, or work-ups that suggested heart disease.
Adair et al. conclude that these findings “suggest that integration of [clinical practice guidelines] into a perioperative protocol has the potential to improve the efficiency of preoperative evaluation, reduce resource utilization, and reduce the time to surgery without sacrificing patient safety.”