JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 67, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2015.10.091
EDITORIAL COMMENT
Are We Doing Too Many Inpatient Echocardiograms? The Answer From Big Data May Surprise You!* Christine L. Jellis, MD, PHD, Brian P. Griffin, MD
I
n this era of health care reform, there is greater
paper by Papolos et al. (2), in this issue of the
scrutiny than ever before of health care–related
Journal, is a timely analysis of echocardiography
costs and appropriateness of testing services.
utility within the U.S. hospital system. With the
There has been a noticeable shift from a practice of
assistance of the Nationwide Inpatient Sample (NIS),
broad diagnostic screening to a more targeted testing
they were able to examine trends in use of echocar-
approach. This new best practice is expected to
diography over a 10-year period from 2001 to 2011.
significantly alter the way that health care is deliv-
This sample encompassed data on approximately 8
ered throughout the United States. Over the last
million annual hospitalizations from approximately
decade, all modalities of echocardiography have
20% of community hospitals in the United States.
rapidly expanded in utility and availability. Transtho-
They then used the data from 2010 to correlate all
racic echocardiography (TTE), in particular, is now
cause in-hospital mortality with echocardiography
routinely available in almost all acute inpatient facil-
utilization.
ities, outpatient centers, and many emergency rooms. Miniaturization of technology has allowed smaller
SEE PAGE 502
and less expensive platforms to be developed, thereby enabling greater access to and more porta-
Papolos et al. (2) began by identifying the most
bility of this technology. The relatively low cost,
commonly associated conditions for which echocar-
absence of radiation, and ability to perform studies
diography is deemed appropriate according to current
at the bedside has placed echocardiography at a sig-
best clinical practice. These included acute myocar-
nificant advantage over other techniques including
dial infarction (AMI), cardiac dysrhythmias, acute
cardiac computer tomography, magnetic resonance
cerebrovascular disease, congestive heart failure,
imaging, and nuclear medicine.
sepsis, coronary artery disease, valvular disease, and
Given this rapidly expanding utility of echocardi-
nonspecific chest pain. Statistical modeling was then
ography, there has been a perception that it is over-
employed to determine the relationship between
used and potentially employed inappropriately in
diagnostic testing and all-cause inpatient mortality.
many instances. Although these claims have never
Given the inherent limitations associated with a
been substantiated, they have gathered traction
database of this nature, the authors subsequently
amongst the medical community and resulted in
replicated and validated their findings within their
documented appropriate use criteria (1). Hence, the
own institution. As expected, they found that the use of inpatient echocardiography has been steadily increasing at an average rate of approximately 3% per annum over the
*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the Department of Cardiovascular Medicine, Cleveland Clinic,
last decade. More importantly and perhaps surprisingly, performance of echocardiography was also associated with reduced inpatient mortality in the first
Cleveland, Ohio. Both authors have reported that they have no
5 of the clinical categories listed previously. Some-
relationships relevant to the contents of this paper to disclose.
what unexpectedly, echocardiography was actually
Jellis and Griffin
JACC VOL. 67, NO. 5, 2016 FEBRUARY 9, 2016:512–4
Are We Doing Too Many Inpatient Echocardiograms?
only performed in 8% of the eligible 3.7 million hos-
differentiate between TTE and transesophageal echo-
pitalizations
indications.
cardiography from the codes utilized within the NIS
Papolos et al. (2) confirmed that echocardiography
database also needs to be acknowledged. However,
was underutilized for these same conditions within
this implies that TTE numbers were even lower than
their own hospital cohort, though to a lesser degree
described and reinforces the message of potential un-
than for the study population as a whole.
derutilization. The apparent protective effect of
for
these
pre-specified
The counterintuitive findings from Papolos et al. (2)
echocardiography may be possibly explained by the
are particularly interesting, as they debunk the
fact that those subjects who received echocardiogra-
widespread perception of echocardiography overuse.
phy also experienced a higher standard of care overall,
Additionally, more importantly, they highlight the low
perhaps facilitated in centers with more subspecialty
utilization of echocardiography in currently recom-
availability. The authors partially refute this by
mended indications such as AMI, heart failure and
showing that there was no difference in distribution of
cerebrovascular disease, even though echocardio-
echocardiography utilization according to medical
graphy use was actually associated with reduced
center size, but clarity regarding other variables is
hospital mortality. These findings may reflect in
beyond the scope of the NIS database. Highest rates of
part the limited availability of echocardiography in
echocardiography use were noted throughout the east
some regional centers or suboptimal “out-of-hours”
coast, arguably substantiating that greater availability
coverage, but it seems hard to believe that accessibility
of subspecialty involvement was an influencing factor
is truly an issue in 92% of admissions for these condi-
in utilization.
tions. Some subjects may have had a recent outpatient
While advocating for increased utilization of
echocardiogram and thus inpatient testing was
echocardiography seems justified based on the find-
thought to be unnecessary. However, if the patient was
ings of this paper, maintenance of quality standards
symptomatic enough to require an acute cardiac
according to approved recommendations remains
admission, surely the change in clinical status should
paramount and is strongly advocated (6). Perfor-
warrant a repeat echocardiogram as is specified in the
mance of echocardiography by inexperienced or
echocardiography appropriateness guidelines (1)? In
unqualified providers could have detrimental effects
this scenario, the costs associated with diagnostic im-
and result in incorrect or missed diagnoses and
aging would be arguably offset by more accurate
inappropriate management. Handheld devices are
diagnosis and subsequent ability to optimize treat-
becoming more popular, particularly in the intensive
ment in a more timely fashion. In fact, the increased
care and emergency room settings, but remain
mortality rates associated with the failure to utilize
limited in diagnostic capability. These platforms also
echocardiography suggest that any additional costs
have minimal ability to record images, thereby
may be justified by superior clinical outcomes.
limiting the ability to corroborate findings or compare
In many ways, the documented annual increase in
for interval change. This is particularly concerning as
echocardiography volume appears relatively modest,
often the patients being examined with these devices
but in keeping with previous findings (3). Another
at the bedside are the sickest, have the most techni-
surprising finding emanating from this analysis is the
cally challenging acoustic windows and have the
paucity of echocardiography use with AMI and coro-
most complicated pathology. Increasingly, too, these
nary artery disease, despite strong guideline recom-
tools are being used by physicians other than cardi-
mendations (4,5). Although approximately two-thirds
ologists who have limited training at best in their use.
of subjects underwent diagnostic coronary catheteri-
At this time, therefore, the use of such alternative
zation with presumed ventriculography, there still
diagnostic tools cannot replace the comprehensive
remained approximately 30% of subjects with both of
evaluation provided by a complete TTE including 2D
these conditions who had no inpatient assessment of
imaging, comprehensive Doppler interrogation and
ventricular systolic function. For those fortunate few
volumetric analysis. In many of these challenging
who did have echocardiography, there was a clear
cases, the further use of echo contrast, 3D imaging
reduction in all cause hospital mortality in the setting
and
of AMI. These findings were corroborated in the au-
experienced operators can have a significant impact
thors’ home institution.
on diagnosis and management (7–9).
even
transesophageal
echocardiography
by
As with most studies, there are some inherent
We live in an era of cost repositioning and evolving
limitations of this manuscript, which limit its gener-
health care policy. Although the charges associated
alizability. Incorrect coding for performance of echo-
with echocardiography must always be considered,
cardiography may have led to an underestimation of
this should not be at the detriment of patient care and
echocardiographic utilization. The inability to clearly
outcomes.
In
comparison
with
other
advanced
513
514
Jellis and Griffin
JACC VOL. 67, NO. 5, 2016 FEBRUARY 9, 2016:512–4
Are We Doing Too Many Inpatient Echocardiograms?
cardiac testing such as cardiac computer tomography
relationship between the use of echocardiography
and magnetic resonance imaging, echocardiography
and better clinical outcomes does not necessarily
often provides better value and is eminently more
imply causality. Prospective studies are required to
practical for sicker patients. The increasing practice
determine if these findings can be replicated more
of “cost bundling,” whereby a fixed fee is paid for the
broadly and if outcomes can be directly influenced by
entire hospital admission, may be a disincentive for
consistently adhering to appropriateness criteria and
repeat diagnostic testing, even if there is a change in
guideline
clinical status and this may be at a potential cost to
echocardiography. In the meantime, this paper
the clinical outcome as suggested by this paper. To
reminds us that underutilization of safe, effective
further reduce inpatient testing and enable billing
technologies such as echocardiography may also have
outside of bundling agreements, scheduling of repeat
a broad economic impact and that health care strate-
echocardiography after discharge is becoming more
gies that may limit their utilization should be sub-
commonplace. In part, these practices may have
jected to clinical trials and the cleansing light of actual
already influenced some of the data presented within
data.
recommendations
for
performance
of
the manuscript as the authors acknowledge. Papolos et al. (2) present a thought provoking
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
insight into the current reality of echocardiography
Brian Griffin, Department of Cardiovascular Medi-
utilization in the United States. Their findings strongly
cine, Desk J1-5, Heart and Vascular Institute, Cleve-
suggest an actual underuse of this technology in con-
land
ditions where it has most proven value. The illustrated
Ohio 44195. E-mail: griffi
[email protected].
Clinic,
9500
Euclid
Avenue,
Cleveland,
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KEY WORDS appropriateness, cost, echocardiography, utility