Appropriateness vs value: Echocardiography in primary care

Background: Despite efforts targeting the growth of healthcare spending within the United States, the current increase in expenditures remains a widespread systemic issue. The overuse of healthcare testing has previously been identified as a modifiable contributing factor. One such test, echocardiography, has seen a continuous increase in its rate of use. This test is frequently ordered by primary-care physicians. Hypothesis.: In the setting of a low likelihood of disease, echocardiography does not substantially change cardiac therapy, even if appropriately ordered. Methods: We randomly identified 500 patients who received an echocardiogram ordered by a primary-care physician between January 1, 2014, and December 31, 2014. Of these, 239 patient charts were reviewed and the following extracted: primary indication for the test, echocardiogram results, and changes in patient medical management. In addition, appropriateness of the test was assessed using the appropriate use criteria guidelines for echocardiography. Results: Nearly 97% of the studies within the ambulatory primary-care setting were appropriately ordered according to the appropriate use criteria. Among the 239 patients studied, only 52 had abnormalities and only 6 (2.5%) experienced a change in management that corresponded with the initial suspected diagnosis and echocardiographic findings. Conclusions: To ensure the greatest value and optimize use of diagnostic testing, it may be necessary to develop a more comprehensive set of guidelines to assist clinicians to readily identify patient populations at low, moderate, and high risk for the presence of disease and provide educational interventions, including feedback regarding individual ordering behaviors.