Echocardiography Enters Appropriate Use Spotlight

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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."