Trends in echocardiography utilization in the Veterans Administration Healthcare System

doi:10.1016/j.ahj.2009.12.015

American Heart Journal

Volume 159, Issue 3, March 2010, Pages 477-483

https://doi.org/10.1016/j.ahj.2009.12.015 Get rights and content

Background

There is growing concern over the impact of accelerating use of diagnostic imaging services on health care spending. Echocardiography is an important cardiovascular imaging procedure, but little is known about trends in its use or utilization. We examine trends in the utilization of echocardiography in a national health care system.

Methods

We used administrative data from the Veterans Healthcare Administration (VA) from 2000 to 2007 to identify patients receiving regular medical care (VA users) or echocardiograms at the VA. We then examined the number of echocardiograms performed each year within the VA and echocardiogram utilization (rates per 1,000 VA users). We examined changes in echocardiogram use and utilization over time and potential overuse of echocardiography.

Results

The number of echocardiograms increased from 92,269 in 2000 to 195,767 in 2007 (a 112.2% increase). Alternatively, echocardiogram utilization remained relatively stable, increasing from 68.8 per 1,000 VA users in 2000 to 71.5 per 1,000 VA users in 2007 because the number of VA users increased by 104.2% over the study period. The mean number of scans per year in echocardiogram recipients remained constant at 1.1/y, and the proportion of recipients receiving multiple scans remained constant at <10%.

Conclusions

Use of echocardiography in the VA increased dramatically between 2000 and 2007, but utilization rates increased only modestly. Our results suggest that, within the VA, growth in the use of echocardiography resulted from an increase in the number of patients receiving care from the VA on regular basis rather than the performance of a greater number of echocardiograms on a fixed patient population.

Section snippets

Data sources

We used VA Patient Treatment Files and Outpatient Care Files to identify all echocardiograms performed between fiscal year 2000 and 2007. The Patient Treatment File contains discharge abstract data for all patients hospitalized in VA medical centers. Key data elements include patient demographics, admission dates, primary and secondary diagnoses, and procedures performed during hospitalization (eg, echocardiography) as defined by International Classification of Diseases Ninth Revision, Clinical

Patient characteristics

Between 2000 and 2007, a total of 1,159,725 echocardiograms were performed in the VA, with the annual number of echocardiograms ranging from 92,269 in 2000 to 195,767 in 2007 (Figure 1). During the same period, the number of patients receiving care increased from 1,341,071 in 2000 to 2,739,215 during 2007 (Figure 1).

Compared with VA users who did not receive echocardiograms, echocardiogram recipients were significantly older and more likely to be of white or black race (Table I). Not

Discussion

In an analysis of VA administrative data, we found that use of echocardiography doubled between 2000 and 2007. Interestingly, and in contrast to our expectation, echocardiography utilization remained relatively constant over our study period. Alternatively, we did find evidence that, since 2004, echocardiogram utilization may be accelerating and an increasing proportion of patients may be receiving multiple studies.

A number of our study findings merit further discussion. First, it is important

Conclusions

We found that, among VA users, the use of echocardiography doubled between 2000 and 2007 but that echocardiogram utilization remained relatively constant, providing a measure of reassurance for those concerned about rapid growth in the use of imaging studies. Alternatively, we did find evidence that, since 2004, echocardiogram utilization has been accelerating and repeated imaging of patients has been on the rise. There is a wide range of geographic variability in echocardiography utilization

Disclosures

Funding sources: Dr Okrah receives fellowship stipend and tuition support from the Cardiovascular Interdisciplinary Research Training Grant, Iowa Cardiovascular Center, University of Iowa Carver College of Medicine. Dr Cram has an appointment in the Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) at the Iowa City VA Medical Center, which is funded through the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and

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Third, most patients only underwent conventional echocardiography; since echocardiography with contrast is superior to conventional echocardiography at detecting LV thrombus,18 it is likely that the incremental yield of detecting LV thrombus on DE-CMR as compared to contrast echocardiography is lower. However, as LV thrombus is rarely the primary indication for echocardiography, most patients undergoing echocardiography for screening of cardiac structure and function will not receive contrast.8 Fourth, although both echocardiography and DE-CMR were performed within the same hospitalization, DE-CMR was performed a median of 2 days after the echocardiography, thus conceivably allowing for the potential formation of LV thrombus in the interim.
Background: The short-term risk of ischemic stroke in patients with left ventricular (LV) thrombus identified via delayed-enhancement cardiac magnetic resonance (DE-CMR) imaging is uncertain. Methods: We performed a retrospective cohort study of patients who underwent DE-CMR for evaluation of LV systolic dysfunction at NewYork-Presbyterian Hospital/Weill Cornell between 2007 and 2016. We identified all hospitalized patients who had DE-CMR evidence of LV thrombus, and as controls, all hospitalized patients who had no DE-CMR evidence of LV thrombus; 2 control patients were randomly selected for each patient with LV thrombus. Our primary outcome was ischemic stroke prior to hospital discharge. Additionally, we compared the risk of stroke among patients with: (1) no LV thrombus, (2) LV thrombus by DE-CMR but not by echocardiography, and (3) LV thrombus by both DE-CMR and echocardiography. Results: We identified 33 patients with LV thrombus and 66 patients without LV thrombus on DE-CMR. Of the 33 patients with LV thrombus on DE-CMR, 13 had echocardiographic evidence of thrombus. Ischemic stroke occurred in 3 of 33 (9.1%; 95% CI, 1.9%-24.3%) patients with LV thrombus on DE-CMR. Ischemic stroke occurred in 0 of 66 (0%; 95% CI, 0%-5.4%) patients without LV thrombus on DE-CMR, 1 of 20 (5.0%; 95% CI, .1%-24.9%) patients with thrombus on DE-CMR but not echocardiogram, and 2 of 13 (15.4%; 95% CI, 1.9%-45.4%) patients with thrombus on both DE-CMR and echocardiogram (P value for comparison among groups, .02). Conclusions: We found a 9% short-term risk of ischemic stroke in patients with LV thrombus detected on DE-CMR.
The National Echocardiography Database Australia (NEDA): Rationale and methodology
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The National Echocardiography Database Australia (NEDA) is a new echocardiography database collecting digital measurements on both a retrospective and prospective basis. To date, echocardiographic data from 435,133 individuals (aged 61.6 ± 17.9 years) with linkage to 59,725 all-cause deaths during a median of 40 months follow-up have been collected. These data will inform a number of initial analyses focusing on pulmonary hypertension, aortic stenosis and the role of artificial intelligence to facilitate accurate diagnoses of cardiac abnormalities.
Association of Liability Concerns with Decisions to Order Echocardiography and Cardiac Stress Tests with Imaging
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Although regional variation in stress testing and echocardiography has been widely documented, the underlying influences are not well understood. Peer behavior and local practice effects, patient characteristics, and health system organizational characteristics all likely play a role in influencing decisions to order imaging stress tests and echocardiography.7,14,24-27 Liability concerns may contribute to practice variation by increasing testing rates in regions of the United States where rates of lawsuits for medical malpractice are high.
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A web-based survey was administered to cardiologists and general practice physicians affiliated with two academic institutions. The survey consisted of four clinical scenarios in which appropriate use criteria rated echocardiography or stress testing as “may be appropriate.” Respondents' degree of liability concerns and risk aversion were measured using validated tools. The primary outcome variable was tendency to order imaging, calculated as the average likelihood to order an imaging test across the clinical scenarios (1 = very unlikely, 6 = very likely). Linear regression models were used to evaluate the association between tendency to order imaging and physician characteristics.
From 420 physicians invited to participate, 108 complete responses were obtained (26% response rate, 54% cardiologists). There was no difference in tendency to order imaging between cardiologists and general practice physicians (3.46 [95% CI, 3.12–3.81] vs 3.15 [95% CI, 2.79–3.51], P = .22). On multivariate analysis, a higher degree of liability concerns was the only significant predictor of decisions to order imaging (mean difference in tendency to order imaging, 0.36; 95% CI, 0.09–0.62; P = .01).
In clinical situations in which performance of cardiac imaging is rated as “may be appropriate” by appropriate use criteria, physicians with higher liability concerns ordered significantly more testing than physicians with lower concerns.
Normal reference values of echocardiographic measurements in young Egyptian adults
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This is still valid despite the appearance of other imaging modalities of the heart.1,2 The number of echocardiographic studies performed yearly in the United States, for instance, is estimated to be more than 20 billion studies.3 Decisions regarding medical, interventional or surgical management of patients are widely based on the results of echocardiography on a daily basis for both cardiac and non-cardiac patients.
Normal values for echocardiographic measurements are widely based on cohorts from North American populations. Differences have been shown to exist that could be attributed to racial and ethnic differences.
To define the normal echocardiographic reference values for various cardiac measurements in young, healthy Egyptian adults.
This study was performed on 1,364 healthy adults aged 18–35 years. Standard trans-thoracic echocardiographic studies were performed to obtain end diastole measurements of left ventricular (LV) posterior wall thickness (PWd), interventricular septum thickness (IVSd), LV internal dimensions at end diastole (LVEDD) and end systole (LVESD), left atrial (LA) diameter, aortic root diameter and right ventricular outflow dimension (RVd). LV ejection fraction (LVEF), LV mass and relative wall thickness were assessed. All measurements were then indexed to body surface area (BSA). Based on our results we proposed normal reference values for young Egyptian adults.
On comparing subjects according to gender, absolute measurements showed males had significantly larger LVEDD, LVESD, IVSd, PWd, LV mass, LA anteroposterior diameter and aortic root diameter (p < 0.0001 for each). LV ejection fraction was higher in females (p = 0.008). There was no difference regarding RVd (p = 0.118). Females had larger indexed LVEDD (p = 0.0003), indexed LA and aortic root diameters (p = 0.0005 and 0.007 respectively) and indexed RVd (p < 0.0001). However, indexed LV mass was larger in males 83.56 ± 20.37 versus 77.76 ± 18.56 g/m² (p < 0.0001). We proposed normal values for absolute and indexed echocardiographic measurements based on our results.
Estimation of local reference values is important to define normalcy. The main difference from international values was a higher upper reference limit for LV mass especially in females and relatively smaller LA dimensions in young Egyptians.
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Increased use of echocardiography (echo) raises questions of whether echo is an overused diagnostic procedure in the United States.
This study investigated national trends, practice patterns, and patient outcomes associated with inpatient echo use reported in the Nationwide Inpatient Sample (NIS).
We identified admission diagnoses most commonly associated with echo use and performed multivariate logistic regression within each diagnosis cohort to assess whether echo use was associated with all-cause inpatient mortality. Secondary analysis was performed within our institution to validate use trends identified in the NIS database.
Between 2001 and 2011, the absolute volume and incidence of echo steadily increased at average annual rates of 3.41% and 3.04%, respectively. In 2010, the use of echo was associated with lower odds of inpatient mortality among hospitalizations for acute myocardial infarction (adjusted odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.63 to 0.86; p < 0.001), cardiac dysrhythmia (adjusted OR: 0.72; 95% CI: 0.55 to 0.94; p = 0.02), acute cerebrovascular disease (adjusted OR: 0.36; 95% CI: 0.31 to 0.42; p < 0.001), congestive heart failure (adjusted OR: 0.82; 95% CI: 0.72 to 0.94; p = 0.005), and sepsis (adjusted OR: 0.77; 95% CI: 0.70 to 0.85; p < 0.001). In 2010, these 5 diagnoses accounted for 3.7 million hospital admissions (9% of all hospitalizations); however, echo was reported in only 8% of cases. Secondary analysis of imaging practices at our institution confirmed underuse of echo among patients who died during hospitalization for indications identified in the NIS database.
Despite increasing rates of performance, echo may be underused during critical cardiovascular hospitalizations.

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Clinical InvestigationImaging and Diagnostic TestingTrends in echocardiography utilization in the Veterans Administration Healthcare System

Background

Methods

Results

Conclusions

Section snippets

Data sources

Patient characteristics

Discussion

Conclusions

Disclosures

Am J Cardiol

J Am Soc Echocardiogr

Am J Cardiol.

J Am Coll Radiol

Jt Comm J Qual Saf

Am J Cardiol

History of echocardiography and its future applications in medicine

Crit Care Med

Joint Commission on Accreditation of Healthcare Organizations. Performance measures

Report to the Congress. Medicare payment policy

Evolving trends in the use of echocardiography: a study of Medicare beneficiaries

J Am Coll Cardiol

How many enrollees come to VA just for pharmacy? Heath Care financing and economics data brief #2004-10

Clinical Investigation
Imaging and Diagnostic Testing
Trends in echocardiography utilization in the Veterans Administration Healthcare System