Putting the comparison of 2008 and 2011 appropriate use criteria for stress echocardiography in perspective: can screening in solid organ transplant be appropriate?

344 The study by Bhatia et al., ‘‘Comparison of the 2008 and 2011 Appropriate Use Criteria for Stress Echocardiography’’ in the current issue of JASE has identified a gap in the literature that at first seems insignificant but upon further examination has very important clinical and cost implications, particularly for academic centers with solidorgan transplantation programs. Patients being considered for solidorgan transplantation may seem a small niche population until one realizes that kidney transplantation alone in the United States has more than quadrupled since 1991. The most recent data from the US Department of Health and Human Services Organ Procurement and Transplantation Network report 23,360 kidney transplantations from January to October 2012 and 117,053 patients on the waiting list. All of these patients (plus those who are evaluated but not listed) will undergo some type of preoperative evaluation, and many will undergo cardiac testing for ‘‘screening’’ purposes. However, survey and registry data have demonstrated that significant variation exists from institution to institution with regard to the ‘‘standard’’ workup of asymptomatic transplantation candidates, ranging from routine coronary angiography to imaging stress testing to no testing at all. Because waiting times before eventual transplantation can be years, repeat cardiac testing compounds the problem, as some professional societies have suggested routine surveillance of waitlisted patients. Suddenly, the numbers start to add up. The observations made in the study by Bhatia et al. at the Massachusetts General Hospital are probably not that far off from the situation at other large hospitals with dedicated solid-organ transplantation programs. The question is, who needs to change? Are clinical practice patterns out of step with appropriateness criteria? Or are appropriateness criteria a step behind with regard to good clinical practice? In the retrospective chart review by Bhatia et al., the 2008 and 2011 appropriate use criteria were applied to a consecutive series of 252 clinically requested stress echocardiograms at a single large academic hospital (Massachusetts General Hospital; requesting providers consisted of 83 different health care providers, of whom 50% were cardiologists), and the appropriateness classifications were examined. An initial review of the results suggests that the 2008 guideline left too many studies unclassified, and the newer