Appropriate, But Ignored? New Echo Study Raises Questions

Shelley Wood

July 23, 2013

CHICAGO, Illinois — A new review of more than 500 transthoracic echocardiograms (TTEs) at a Texas medical center suggests that, although the vast majority were "appropriate," one in five tests had no discernible impact on patient care and half simply led to a "continuation" of how the patient was already being managed [1].

The authors, led by Dr Susan A Matulevicius (UT Southwestern Medical Center, Dallas, TX), say their findings, although retrospective, should prompt a good hard look at the reasons TTEs are ordered and whether current appropriate use criteria (AUC), published in 2011, lead to clinically meaningful use.

"I'm an echocardiographer myself," Matulevicius told heartwire . "The fact is that for a tool that is so powerful for its diagnostic ability, it was a little surprising how much less clinically useful it appears to be. . . . Currently, as implemented, I don't think the AUC are efficiently optimizing the care of patients through the use of echocardiography."

Physicians who order or perform echocardiograms tend to "fall back" on the idea that echo is an easy, noninvasive, relatively low-cost test, so the bar for a pretest likelihood of finding something that would lead to a change in care is set quite low, she added. "People tend to think, what is it hurting? But if we take a step back, it is kind of hurting, in that we are using dollars that we could have spent elsewhere."

A Bar Set Low

Matulevicius and colleagues reviewed 535 electronic medical records (EMRs) for all TTEs performed over a one-month period for which clinical data were also available. (TTE performed after cardiac transplant or left ventricular assist device implantation were excluded.) Two independent cardiologists reviewed the EMRs to determine appropriateness using the 2011 AUC, and were blinded to the TTE results and subsequent clinical course of patients. Two different cardiologists blinded to the AUC classifications independently assessed the clinical impact of the tests.

In all, 91.8% of TTEs were deemed appropriate, 3.9% uncertain, and 4.3% inappropriate. On the other hand, just 31.8% of TTEs led to an active change in care and 46.9% lead to continuation of care, defined as no escalation or de-escalation of current care, but direct communication to patients and/or documentation of the results in the medical record. Finally, 21.3% led to "no change in care," which Matulevicius et al defined as situations in which the next step in the patient's management was already in place before the TTE was done; the planned management was in place regardless of what the echo showed; or a previous TTE was already in the records with no explanation as to why a new one was needed.

"The discrepancy between appropriateness and clinical impact is striking and suggests that the AUC as currently implemented are unlikely to facilitate optimal use of TTE," the authors conclude. "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."

In the Absence of Appropriate(Ness) Studies

Matulevicius et al's paper is accompanied by two invited commentaries [2,3]. In one, Dr John PA Ioannidis (Stanford University School of Medicine, CA) points out that, despite the fact that TTEs cost more than $1 billion per year to Medicare alone (and are the most commonly ordered cardiac imaging test), most of the AUC intended to guide their use have level of evidence B or C, or no level of evidence at all.

"This worrisome pattern of experts grading recommendations without data or with limited data is highly prevalent across diverse prestigious guidelines," he notes. For TTE, he argues, "larger trials for more common indications of TTE that evaluate major clinical outcomes should be feasible. Until more definitive studies such as these are performed, the distinction of what is appropriate vs clinically useful will remain difficult."

Taking a different approach, Drs William Armstrong and Kim A Eagle (University of Michigan Medical Center, Ann Arbor) argue that the analysis by Matulevicius and colleagues may offer more of a comment on medical recordkeeping than on utility of TTE. They point to a number of clinical settings deemed appropriate in the 2011 AUC, yet which led to high rates of "no change" in clinical care in the study--things like suspected pulmonary hypertension and baseline/serial review of patients receiving cardiotoxic agents. In both settings, TTE results are important, even if no change takes place in the patient's pattern of care, they note.

The designation of "no change," they argue, may perhaps reflect "more on absence of documentation than . . . total disregard for or ignorance of echocardiographic results."

What this study supports, they argue, are educational initiatives targeting "appropriate use of results (rather than just appropriate ordering). . . . This retrospective study points the way for further prospective studies looking at the impact of echocardiography and how it affects physician decision making."

In response, Matulevicius told heartwire that both commentaries make important points, but she had some rebuttals.

A key issue, she notes, is that "diagnostic testing, unlike therapeutic interventions, have mostly been evaluated by their ability to detect disease (sensitivity and specificity) and not how that information affects patient care. Without a standardized definition of what is an acceptable and valuable outcome of diagnostic testing like TTE, it will be difficult to compare diagnostic evaluation and management strategies that involve more vs less testing."

And although randomized trials are the gold standard, Matulevicius argues that observational data, ideally prospectively collected, "that can examine the patient, physician, and system characteristics associated with echocardiograms that result in active change or continuation of care, are paramount to evaluating how TTE can optimally be utilized in the process of delivering high value care."

To Eagle and Armstrongs' point about physician education, she says she 100% agrees. "Simple interventions, like asking physicians what they expect to learn from the test and what they are planning to do with those results may make physicians more accountable and thoughtful in their decision-making process and reduce the number of tests that are ordered just because they can be ordered."

She stressed that there will always be situations in which there is no active change. "You need normal [results] sometimes too, because you don't want to miss the times when you could have intervened earlier," she said. "But there are two extremes [in whom TTEs are often ordered unnecessarily]: people who are completely healthy who--if I had to lay money on it--I would say are going to be normal, and the other extreme, where people are very ill and are already having everything done. Those are two groups that need to be studied further."

Practice-Changing

Matulevicius says that the study findings have influenced her own practice, primarily in instances where she is using echo to reassure patients. "There are always some people in whom it is easy to get their history, and get them a test, and show them their heart is normal, when you think it is normal. It's time-saving, and I'm getting paid--or my division is getting paid--for doing that test, and when it's normal, and that's what I thought it was going to be, I can give the patient good news."

Now, she says, "I'm doing the opposite." It takes longer than ordering a test, but now with patients she is confident are normal, she discusses the fact that a test is not needed, she talks about diet, exercise, and stress management, and takes the time to set expectations and make a treatment plan. If these kinds of conversations were reimbursed at the same level as an echocardiogram, she notes, "I think you could keep patient expectations high, and have outcomes that are as good or better [than ordering a TTE]."

The authors of the study and commentaries had no conflicts of interest.

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