Cardiologists who used a handheld ultrasound were more likely to make an accurate diagnosis of patients with common cardiovascular abnormalities than colleagues who relied on a physical exam, for an estimated savings of $63 per patient. Handheld ultrasound’s ability to rule out abnormalities also likely would reduce downstream testing, according to a study published online Sept. 17 in the Journal of the American College of Cardiology: Cardiovascular Imaging.
Cardiologists and other practicing physicians may resist using handheld ultrasound for several perceived reasons: the need for training; concerns that it takes more time; distrust in its accuracy; lack of financial incentives; and the potential loss of downstream revenue from echocardiograms, among others. Manish Mehta, MD, of the Knight Cardiovascular Institute at Oregon Health and Science University in Portland, and colleagues challenged some of those arguments with a prospective study that compared handheld ultrasound with physical examination.
They enrolled 250 patients with suspected cardiovascular abnormalities who were admitted to the hospital and referred for transthoracic echocardiograms. Each patient received an echo exam, which served as the reference standard. A board certified cardiologist who was told the indication but was blinded to the imaging results then examined the patient. A different board certified cardiologist with the same limited information performed a physical examination the same day. All cardiologists filled out a form to note their findings and whether they recommended more testing.
Based on the echocardiogram, 142 patients had at least one finding of an abnormality. Cardiologists using a handheld ultrasound correctly identified 82 percent of those patients while physicians using a physical exam correctly identified 47 percent.
Both methods reliably ruled out substantial valve disease but handheld ultrasound was better at spotting its presence. It was also superior at assessing left ventricle function in 172 patients referred for chest pain or dyspnea, correctly identifying 88 percent vs. 45 percent by physical exam.
Most physicians recommended further testing in the 142 patients who had at least one finding of an abnormality on echocardiogram (91 percent for handheld ultrasound and 90 percent for physical exam). But of the 108 patients with no abnormalities on echocardiogram, more testing was called for in 82 percent of patients after a physical exam and 56 percent after a handheld ultrasound exam.
Based on models, Mehta et al estimated the cost of a physical exam totaled $707.44 vs. $644.43 for a handheld ultrasound exam. Assuming additional testing took a half day, costs grew to $1,415.44 for a physical exam and $1,262.43 for a handheld ultrasound exam.
The findings showed that handheld ultrasound provides a more accurate diagnosis and is less likely to contribute to downstream testing, they wrote.
Using handheld ultrasound took a mean eight minutes compared with five minutes for the physical exam. “For the additional time taken, and given that HHU [handheld ultrasound] use can potentially reduce cost to the system, its use makes sense and should be incentivized,” they proposed.
They recommended larger comparative studies that included primary care physicians and midlevel practitioners be done to assess the impact on outcomes and downstream costs.