Patient Sociodemographic and Provider Characteristic Predictors of Echocardiogram Ordering in Pediatric Patients: A Retrospective Analysis.

Implicit bias and socioeconomic factors may influence diagnostic testing in pediatrics, but their effects on echocardiogram ordering in outpatient pediatric cardiology are not well understood. We evaluated whether patient demographics, insurance type, neighborhood Childhood Opportunity Index (COI), and provider characteristics (years of experience, degree attained, gender) were associated with guideline-concordant echocardiogram ordering for initial outpatient evaluation of pediatric chest pain. We conducted a retrospective study of 299 pediatric patients undergoing initial outpatient evaluation for chest pain between 2018 and 2024 at the University of Maryland Children's Hospital outpatient cardiology clinics. Echocardiogram appropriateness was determined using previously published appropriate use criteria (AUC) and structured clinical management and assessment plan (SCAMP) criteria. Associations between patient and provider factors and echocardiogram appropriateness were assessed. Echocardiogram ordering was concordant with AUC/SCAMP recommendations in 232 encounters (77.6%). White patients were more likely than non-White patients to receive guideline-concordant ordering (83.8% vs. 72.8%, p = .025). Patients from "Moderate", "Low", or "Very Low" COI neighborhoods were more likely to receive a non-indicated echocardiogram (27.5%, 31.3%, and 20%) compared to patients with "High" or "Very High" COI (16.4% and 14.4%) (p=.019). Providers with less than 10 years of experience were more likely to order echocardiograms in concordance with AUC/SCAMP criteria (86.9% vs. 71.2%, p < .001). Most echocardiogram ordering was guideline-concordant; however, deviations from guidelines were associated with patient race, neighborhood COI, and provider experience. Non-White patients and those from lower COI neighborhoods received more non-indicated echocardiograms than White patients or those from higher COI neighborhoods. These findings identify opportunities to improve equitable, guideline-concordant care in outpatient pediatric cardiology.