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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4. Amsterdam EA, Wenger NK, Brindis RG, et al.

7. Kurt M, Shaikh KA, Peterson L, et al. Impact of

AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure

2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64: e139–228.

contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort. J Am Coll Cardiol 2009; 53:802–10.

Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Coll Cardiol 2011;57:1126–66. 2. Papolos A, Narula J, Bavishi C, Chaudhry FA, Sengupta PP. U.S. hospital use of echocardiography: insights from the nationwide inpatient sample. J Am Coll Cardiol 2016;67:502–11. 3. Okrah K, Vaughan-Sarrazin M, Cram P. Trends in echocardiography utilization in the Veterans Administration Healthcare System. Am Heart J 2010;159:477–83.

5. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44:

8. Stanton T, Jenkins C, Haluska BA, Marwick TH. Association of outcome with left ventricular parameters measured by two-dimensional and threedimensional echocardiography in patients at high cardiovascular risk. J Am Soc Echocardiogr 2014; 27:65–73.

671–719.

9. Sheikh KH, de Bruijn NP, Rankin JS, et al. The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery. J Am Coll Cardiol 1990;15: 363–72.

6. Picard MH, Adams D, Bierig SM, et al. American Society of Echocardiography recommendations for quality echocardiography laboratory operations. J Am Soc Echocardiogr 2011;24:1–10.

KEY WORDS appropriateness, cost, echocardiography, utility

Are We Doing Too Many Inpatient Echocardiograms?: The Answer From Big Data May Surprise You!

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