Cardiologists take issue with study on echocardiogram overuse

The American College of Cardiology interprets results of a new study on use of echocardiograms differently from the University of Texas Southwestern researchers who put it together.

The study appeared online July 22 in JAMA Internal Medicine (link). Authors say that because transthoracic echocardiography results in no change in care nearly 20% of the time, and only one in three screenings results in an active care change, some of the money spent on the tests could be used better elsewhere.

“Everything doesn’t result in a change,” said Eugene Sherman, MD, chair of ACC’s advocacy steering committee.

He gives an example of classic echo use: A patient has physical findings of noncritical aortic stenosis, but then has chest pains or faints, indicating that the stenosis is more significant. If the doctor orders an echo and the patient does not have critical aortic stenosis, you don’t do a heart catheterization, he says.

“By [the researchers’] criteria, that would say no change in therapy. That, to us, means you saved someone going through the cath lab. … There’s no way to measure that by the way they’ve done this,” Dr. Sherman said.

Proof of appropriate use

Dr. Sherman points out that the study shows that 92% of the tests were found to meet the appropriate use criteria the ACC established for the tests (link). He said he would like to see further study to understand how and why physicians order the tests and how they use them.

In an invited commentary, William Armstrong, MD, and Kim Eagle, MD, of the University of Michigan Health System, agreed that further prospective studies were needed and that educational initiatives targeting appropriate use of results, rather than just appropriate ordering, may get at some of the concerns raised by the study (link).

Echocardiograms make up more than half of all cardiac imaging. Medicare pays between $200 and $450 for each test and its reading, according to the ACC. In 2010, those tests make up $1.1 billion of total Medicare diagnostic imaging spending, according to the study’s authors, who say some of that money is wasted.

Lead study author Susan Matulevicius, MD, an assistant professor of internal medicine at UTSW Medical Center, said that even if the results only reassure the patient that the current management is working, that’s a reasonable cause for the test. But she said too often the tests are ordered reflexively for people unlikely to benefit from the results.

“I still think that echo is an extraordinarily important test, and I think it gives you a lot of information relatively quickly with very little risk to the patient, but I think that’s also where it can be overused, because it’s so low risk,” Dr. Matulevicius said.

Second study claims overuse

Another study posted online July 22 in JAMA Internal Medicine by researchers in Norway found no benefit over 15 years in ordering echocardiograms to assess cardiovascular risk in individuals in the general population without symptoms of heart failure, or a family history of sudden death or inherited heart disease.

Lead study author Dr. Haakon Lindekleiv of the University of Tromso in Norway, said his research supports the notion that echocardiography is overused (link).

There are two major problems with unwarranted testing, he said.

“The first is a financial one: Ordering echos is not cost-effective if it is unlikely to improve the patient’s health or prevent disease progression,” he stated in an email. “Second, unwarranted testing may be harmful to the patient as cardiac workup due to incidental findings on the echocardiogram may lead to anxiety, psychological harm and complications with little benefit.”