Echocardiography Enters Appropriate Use Spotlight
Tremendous attention has been focused on the overutilization of imaging, especially cardiovascular imaging. To counteract this trend, the cardiology and echocardiography communities have developed several new appropriate use criteria (AUC) documents since 2007, as well as a document that seeks to ensure quality in echocardiography laboratory operations. However, only when these recommendations are integrated at the point of care, with the assistance of health IT, will echo undergo acceptance and utilization in real-life clinical practice to improve quality.

Appropriate use

During the past five years, medical imaging utilization has grown substantially, with Medicare Part B costs alone increasing 105 percent from $6.89 billion in 2000 to $14.11 billion in 2005. One-third of these exams are attributed to cardiovascular imaging (Circulation 2006;113:374-379).

"As insurance companies and governmental payors are increasing the level of scrutiny for echo, along with why tests are ordered, providers have become more aware of the issue and the need for appropriate use criteria," says R. Parker Ward, MD, cardiologist at the University of Chicago Medical Center. "Gradually, utilization is changing as people are educated to the reasons for potential misuse or overuse of echo in the past."

Also, if appropriate use criteria are properly utilized, practices can transparently show their adherence to evidence-based medicine, and therefore, not be subject to the forthcoming penalties for over-utilization. "There are efforts with the echo appropriate use criteria to get payors to use them very directly in quality improvement methods to optimize utilization, as opposed to reducing utilization through  punitive ways to prohibit or discourage  provider usage via reimbursement cuts," says Pamela S. Douglas, MD, a cardiologist at Duke University Medical Center in Durham, N.C.

"It's always preferred that physicians set the standards of care and utilization, rather than an external body, which won't be as familiar with our processes and the needs of our patients," says Michael H. Picard, MD, director of clinical echocardiography at Massachusetts General Hospital in Boston. "As payors are starting to regulate through pre-authorization processes for multiple imaging tests to reduce costs and proliferation, we want to ensure that the appropriate, high-quality tests are being conducted and repetition is avoided. Therefore, it is the right time to develop these quality standards, as the model of how we deliver care is changing, and presenting a unique opportunity to institute these practice modifications."

The growing use of radiology benefits managers (RBMs) to permit the use of certain imaging prior to its undertaking can potentially stunt practice workflow.  AUC, on the other hand, can enable a payor to examine a lab's performance in a longitudinal fashion to assess whether that practice is performing more than the average number of inappropriate studies compared with other similar-sized laboratories, Douglas explains. "Equipped with the AUC, the payor can point to practice patterns to see whether they adequately reflect the needs of the patients or not," she adds.  

In 2007, there was an AUC released for stress echo; a year later, the criteria were released for transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE). For AUC to be utilized in clinical practice, they need to remain up to date.

Therefore, in January, the American College of Cardiology Foundation (ACCF)—in partnership with the American Society of Echocardiography (ASE)—along with several other specialty societies, published an updated AUC of common clinical scenarios where echocardiography is frequently considered. Some 202 indications were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 (J Am Coll Cardiol 2011;57:1126-1166).

Douglas, who is chair of the AUC writing committee, says that she and her colleagues decided to create an "early revision" to make a more comprehensive set of guidelines that combined stress echo, TEE and TTE in one source document.

"While the original criteria worked very well and helped to stratify utilization in echo practice, there were a few gaps," says Ward. "There were a few missing clinical scenarios, reasons that practitioners could order echoes that were not covered and some new evidence emerged. The new criteria better reflect what we know to be appropriate clinical practice."

How does AUC work?

To properly utilize AUC protocols at the point of care, most physicians concur that health IT is essential. The 2007 AUC for echo is a 38-page paper document with approximately 50 indications, which Ward acknowledges is "fairly cumbersome" to employ in real-life clinical practice. The 2011 version has 202 indications.

"There is virtually no way somebody can look at all the indications in the course of a busy day," Ward explains. "Therefore, it became obvious that we were going to need a web-based application using a computerized decision tree analysis to pool together all the existing criteria."

Using the 2007 document, Ward and colleagues created a portal of entry for common echo indications, such as patient symptomatology. "We combined several indications to allow people to choose from relatively few options, immediately routing them to a few additional questions, and ultimately leading to the relevant AUC indication," Ward explains.

The outcomes of the Echo AUC App were prospectively evaluated. Of the 258 studies enrolled, the Echo AUC App determined TTE indications were appropriate in 77 percent, inappropriate in 9 percent and not classified in 14 percent. The mean study entry time with the application was 55 seconds.

The authors concluded that their results demonstrate that a "web-based application of the AUC for echocardiography represents a practical and feasible instrument with which echocardiography can track and report the appropriateness of procedures" (J Am Soc of Echocardiogr 2011;24(3):271-276).

However, the hard-copy version of the AUC may have a role in retrospectively evaluating practice patterns. Based on the 2007 TTE/TEE criteria, Karthikeyan Ananth, MD, and colleagues at Henry Ford Hospital in Detroit, sought to evaluate its patterns for TTE and TEE ordering in 198 consecutive outpatients over a sixth-month period (presented at ACC.10). Assessing all TTE and TEE utilization, 73 percent of their studies were deemed "appropriate." Importantly, 90 percent of the studies that were deemed "uncertain" were not classifiable by the 2007 AUC—again reinforcing the need for the newest document, released in January.

Ananth says that Henry Ford, which performs about 20,000 echoes annually, is now working on a homegrown IT application, as the "best utilization of AUC is at the point of care." He notes that the ACC and other societies are working to create and disseminate such a point-of-care tool, which can provide real-time feedback.

Ward and his colleagues created the Echo AUC App prototype used in the study, which the ASE developed into a more sophisticated technology. However, he says the ultimate goal is to receive an answer in less than one minute that is fully substantiated by the proper indications.

He adds that efficient IT applications, especially those technologies accessible on a PDA that allow the provider to better employ evidence-based medicine in a rapid fashion are "integral" to the AUC acceptance integration into the provider setting. "Contemporary clinical practice is moving so fast that anything that significantly slows it down or doesn't work incredibly efficiently is not going to be successful," he adds.

Ward isn't the only champion of the need for IT for better AUC utilization. Until EMRs and CPOEs become more widespread, the adoption of AUC at the point of test ordering is "unlikely to occur," writes Ella A. Kazerooni, MD, director of cardiothoracic radiology at University of Michigan in Ann Arbor, who adds that even with "healthcare reform and financial inducements, the implementation of EMR systems will be slow," (Am J Roentgenol 2010;195:968-973).

Who's ordering the study?

The clinical decision about ordering a study often happens before the cardiologist sees the patient, so multiple questions have been raised about who should order imaging studies, and how aware these ordering providers are of the AUC and guidelines.

"While point-of-care applications can prove successful in the echo labs where patients come for their studies, the obvious next step would be its potential use at the point of order, or in the physician's office, where the decision to order the study is usually made," Ward says.

There are many who suggest that the biggest guarantee of not performing inappropriate studies would be to control who orders the study. "Cardiologists spend the most time performing echo, referring for echo and are privy to the most updated guidelines on the indications and benefits of echo," Ward says. "We find that the appropriateness rate among cardiologists is actually higher than that of other specialties, such as primary care physicians."

Therefore, one of challenges, according to Ward, is to educate all the referrers. "Echo is ordered by specialties across the board of medicine and one of the challenges is to try and educate [referrers] and make sure we're improving practice from all specialties." Therefore, a point-of-care clinical decision support tool should seek to assist these caregivers as well.

Interestingly, in the ACC.10 study of both cardiologists and non-cardiologists throughout Henry Ford, Ananth et al found that the non-cardiologists ordered more "appropriate" (56.5 percent) studies than cardiologists (43 percent), but also more "inappropriate" studies (75 percent). "Without a point-of-care tool, it is truly difficult to understand the motivation of the physician, as a health record can only hold a finite amount of information," Ananth says. "Before we can determine a study as inappropriate or appropriate, we have to understand the clinical judgment involved with making that decision."

Right-sizing, not down-sizing

Despite the critical focus on overuse of imaging, there are imaging tests deemed to be essential for quality care for patients that are not being performed. Therefore, Douglas suggests the focus needs to be "right-sizing, as opposed to down-sizing."

For example, the use of echocardiography, as well as other imaging modalities, in the evaluation of ejection fraction after a new diagnosis of heart failure, which is a Class I ACC/AHA practice

guideline recommendation, as well as a Performance Measure for heart failure. Echo is one of a handful of interventions that is highly recommended to be conducted for patients with heart failure.

Yet, Medicare billing data showed that such imaging was actually being under-performed to measure ejection fraction, at only 60 to 65 percent of the time (Circ Cardiovasc Imaging 2009;2:339-348).

"We have some instances with very strong agreement in which echo should be used, and it's not being ordered. Therefore, if the message is only to perform fewer tests, then certain studies may not be performed in areas where they should be," Douglas says.  

These considerations also speak to the need of physicians to employ clinical judgment, even when evaluating AUC. Most of the AUC implementation studies have examined nuclear imaging and echo, yielding similar results—between 10 and 20 percent inappropriate use, according to Douglas. She acknowledges that "there may be a clinical reason that supersedes the AUC, as they are not 100 percent cookbook recommendations. However, if a laboratory or a practitioner starts to creep above 20 percent, it could be a red flag."

The same could be said, however, if the provider falls too far below the AUC. "It could indicate that they have followed the criteria too lavishly, and are not taking into consideration the individual patient's needs," Douglas says.

Ensuring quality in the lab

The guidelines and the AUC do not specifically address how to implement them in a laboratory, but instead cite examples of research on the surveyed use of echo. "However, forward-thinking practices take the guidelines and use them to create education materials and web-based decision tools," Douglas says.

Also, the Intersocietal Accreditation Committee for Echocardiography Laboratories (ICAEL) is changing its accreditation requirements to include attention to appropriate use criteria and utilization of the techniques. "The implementation is currently in the hands of the users and the evaluators, but it starts with a robust set of guidelines with broad, unified support for the criteria," she adds.

To assist these practices, Picard et al compiled the "ASE Recommendations for Quality Echocardiography Laboratory Operations," with the goal of clarifying some benchmarks and boundaries to establish a foundation for minimal standards for echocardiography quality in the practical setting of the echo lab. "The hope is that this is a process that will build and grow," Picard says.

The authors write that "there has been limited agreement on quality standards for imaging" (J Am Soc of Echocardiogr; published online in January). However, Picard points out that this "doesn't indicate a controversy, but instead a void. Quality in imaging has been incredibly hard to define, so until now, the definition has been relatively deficient."

The recommendations are specific about the various processes of echo utilization in the lab. For instance, the authors suggest that patient selection and test ordering is particularly important for TEE because it is an invasive procedure, and should be performed by a specially trained physician. Picard adds that oftentimes, cardiologists have very little to say about which patients are imaged in the echo lab for TTE; however, with TEE, physicians should be involved with which patients undergo the test. "We always have to balance the benefit and the risk," Picard says. "TEE presents the rare occasion where the echocardiographer and the cardiologist can play a role in tailoring the right diagnostic test and the right procedure to the appropriate patient."

He adds that TEE is finding a "firm foothold" in patients with valvular disease, especially now with more treatment options for structural heart disease emerging. "As we start to examine percutaneous interventions for valve diseases—both the mitral and the aortic—TEE is a tremendously helpful exam to identify which patients are eligible for those procedures, as well as guiding the procedures in the cath lab," he says.

However, Picard notes that the interventionalist cannot feasibly perform the procedure, as well as the imaging at the same time; therefore, an echocardiographer may end up guiding the imaging component.   

These recommendations also tackle quality assessment and quality improvement programs, which "easily can be tailored to the specific needs of each facility," Picard says. The document suggests that "at least two echocardiograms for each modality (i.e., TTE, stress echo, TEE) interpreted by each reader should be randomly selected and blindly interpreted by another echocardiographer."

In tailoring to the needs of the lab, Picard acknowledges that a high-volume echo lab will not be able to peer review as many cases, but smaller labs or those that have operators with less experience may require a different frequency. However the ultimate goal is that the process gets put into place.

"The 'holy grail' is improved quality of care, but this is difficult to assess in imaging because patient outcomes are rarely directly dependent on the performance of a diagnostic test," writes Douglas (J Am Soc of Echocardiogr 2008;21(9):1016-1017). "Quality is our issue as healthcare providers,  and one for which the price of not leading can be exorbitant. We must learn to measure quality effectively, and payors must be convinced that they should seek to reward value over volume."