Echo Under Attack in the Press

The ASE leadership has read with interest two studies published in the recent JAMA Internal Medicine regarding the use of transthoracic echocardiograms. The first study, “Echocardiographic Screening of the General Population and Long-term Survival” (screening study) from Norway, demonstrates that screening echocardiograms performed on the asymptomatic general population do not affect survival. A very small number of serious cardiac abnormalities were found in the echo group and it is no surprise that there was no impact on the populations’ health. Screening echocardiograms on asymptomatic subjects are considered inappropriate under the 2011 AUC criteria. The second study, “Appropriate Use and Clinical Impact of Transthoracic Echocardiography” (AUC study), was a retrospective review of the clinical impact of one month’s worth of transthoracic echocardiograms at an academic medical center in Texas. The study is interesting but the difficulties with the analysis are well laid out in the accompanying editorial by Drs. William Armstrong and Kim Eagle (Commentary).

The lay press has responded to these studies by focusing on some of the data but has taken much of the data out of context. These studies, as well as the negative slant of many of the accompanying articles in the lay press, could have an adverse effect in today’s regulatory environment, where echocardiography reimbursements are continuously at risk of being reduced. In fact, government officials often use such studies, and their implication of overuse of echo, as justification for further cuts.

The Texas study purported to show that only 32% of the echocardiograms resulted in “active change in care” while 47% resulted in “continuation of care” and 21% in “no change of care”. The problems with retrospective review of EMR to determine the clinical significance of an echocardiogram is certainly a major drawback of the study since the thought processes of the clinicians ordering the echo and using the results may not be clearly laid out in the EMR. However, most disturbing is the conclusion in the press that since only 32% of echocardiograms resulted in a change in care, significant savings could be achieved by eliminating most of the other studies. Lost in the coverage is the understanding that “continuation of current care” has a clinical impact as significant as a “change in care”. For example, demonstration that the LV function remains normal would allow a patient to continue to receive potentially cardiotoxic but life-saving chemotherapy. Even “no change of care” has clinical impact in many situations.

Your patients may ask about the results of these studies and question the need for an echocardiogram. The ASE stands for quality and value in echocardiography.

  1. The Appropriate Use Criteria for Echocardiography (AUC) was revised by the ASE in partnership with the American College of Cardiology and other subspecialty organizations in 2011 to help define the conditions under which specific tests could be performed based on an evidence-based approach to cardiac care. It is not a guideline and does not directly instruct the care that should be given, but it helps elucidate the reasons that echocardiograms may be clinically necessary. However, while the indication for echo may be in the “appropriate” category, the document does not direct the physician to perform echocardiography should it be unnecessary.
  2. Echocardiography is often appropriately used to determine if heart function has been changed from treatment, for instance from the effects of chemotherapy or in cardiomyopathy. Therefore, it is very incorrect to assume that the results from the echocardiogram offered “no benefit” even if therapy was not changed.
  3. The study was a retrospective medical record review which limits the understanding of the data as it doesn’t take into account what the doctor was thinking when they ordered the echocardiogram.
  4. ASE does not support using echo to screen low-risk, asymptomatic patients, and the AUC also do not endorse this type of generalized screening. ASE has made efforts, through the Choosing Wisely® campaign, to combat the use of testing that is not appropriate for patients.
  5. All medical tests must be subjected to the same criteria: Will it help my patient? What are the dangers of the test? How will I use the information? Is the information available in another form (previous test, other modality, etc)

Please remember that the importance of echocardiography in the care of our patients should not be understated. If you see misleading coverage in your local press or favorite website, please consider writing a letter to the editor. Also, consider a letter to your Representative or Senator, or blog about it on your favorite websites.