In some situations, echocardiography is appropriate and beneficial even if not change in therapy results. For example, echocardiography is the only realistic method for determining the presence or absence of pulmonary hypertension. However, a new study suggests that for far too many patients, echocardiography doesn’t lead to any change in active care—even when the procedure is performed for an appropriate indication. At a cost of more than $1 billion per year to Medicare alone, can the U.S. healthcare system continue to support this?
A study of the use of transthoracic echocardiography (TTE), also known as a cardiac echocardiogram, suggests that most of the procedures were used appropriately under 2011 appropriate use criteria (AUC). However, less than 1 in 3 of the TTEs resulted in an active change in care.
Echocardiography is a safe, noninvasive tool to image the heart without the use of radiation. For this reason it has become the most frequently used method to look at the heart for a wide variety of medical indications.
Researchers from the University of Texas Medical Center studied 535 patients undergoing TTE in April 2011. Overall, 9 out of 10 of the procedures met the 2011 AUC. However, only 31.8% of TTEs resulted in an active change in care; 46.9% resulted in a continuation of current care; and 21.3% prompted no change in care. The study demonstrated that although a test or procedure may be appropriate, it may not necessarily be useful or lead to improved outcomes. An editorial published alongside the article suggests that part of the problem may be that the criteria used to establish the AUC are of average to poor evidence—with 87% of the criteria having either a B or C level evidence rating; 11% of the evidence had inadequate evidence.
According to background information in the article, TEE is the most popular cardiac imaging study; approximately 700 TTE studies are performed annually per 1,000 Medicare beneficiaries at a cost of more than $1 billion per year to Medicare alone.
The authors believe that their findings, although retrospective, should prompt a hard look at the reasons TTEs are ordered and whether current AUC lead to clinically meaningful use. The low rate of active change in care (31.8%) among patients who underwent TTEs highlights the need for a better method to determine which patients are likely to be gain the most from the cost of the procedure. This will be especially important as limited healthcare resources mandate difficult choices.
Given the importance of responsible use of limited medical resources and the need to control increasing health care costs, additional research into the necessity of TTE in the process of medical care is needed and will require collaboration among hospitals, administrators, politicians, economists, the government, and patients.