Dr. Topol,

 Just as with cath and nuclear stress testing, reimbursement will end up being limited to those indications deemed by professional appropriateness criteria to be legitimate.  Indications such as "pre-op", "abnormal EKG", etc, will end up not being reimbursable for the provider.  In diagnostic cath and more importantly, PCI, limiting reimbursement to areas where the ACC/AHA/SCAI have suggested appropriate (http://onlinelibrary.wiley.com/doi/10.1002/ccd.21964/pdf)  will end up becoming the standard for deciding reimbursement.

The question will be how will third party payers recognize whether the documentation justifying a procedure is reasonable or has been otherwise massaged, and that is likely where accreditation from ACE and/or other surveillance means will have to take place.

There have been and will be occasions where I have ordered a test or performed a procedure outside of the recommendations.  The rationale was sound, thought and discussed extensively with the patient and colleagues, and then performed.  In the future, these exceptions likely will not be reimbursed, which probably means they will happen as the exception, and not the rule.

The problem with this approach is that it will prevent the field from pushing the envelope, or advancing the field in major ways.  This in itself is a shame.  But with the need to control costs becoming ever more urgent, these steps seem inevitable.  Cardiology happens to be on the forefront of this because of the leaders in the field who have collected the data to be able to create these guidelines/ appropriateness criteria.

Eric, you see the prolific use of echo as a bad thing. I just don't get this. In your era you were trained to use the stethoscope on every patient. How accurate was that approach? Now that we have echo as the new-world stethoscope we all know that the old way was very unreliable. Echo is (effectively) painless, harmless and very convenient in complete contrast to myocardial perfusion, CT, MRI etc etc.

The second issue is one of litigation. If someone presents with palpatations, chest pain, or just about any cardiac symptom would you be brave enough not to order an echo? Do you really think a clinical examination would be reliable enough or even stand up in court? I completely agree that a completely asymptomatic patient with low CVS risk should not undergo an echo, but how many of our patients are these?

What we are really talking about here is not the medical indication for echo but the lack of funding in the USA for an adequate health system. Echo machines cost money, (good) training is expensive, and yes, echos indirectly cost more money to the health system because they detect disease that would have gone undetected previously - but is this a bad thing?

Maybe we should have an 'echo free hour' , a bit like 'earth hour' and see how long we would survive as cardiologists. I suspect this would put and end to a debate like this.

It's refreshing to hear someone from our fraternity questioning the ridiculous and capricious over performance of echocardiograms that have a minimal positive diagnostic yield for conditions such as chest pain, tachycardia and shortness of breath in adolescents. I see far too many cases each week of teenagers complaining of chest pain that by a performing decent history and physical can be clearly diagnosed as costochondritis who have been sent by their primary care physicians for a totally unnecessary echocardiogram. What should be no more than a $250 to $300 charge now becomes a $1500 charge. Multiply this by who knows how many thousands of patients are handled this way across the country and consider the enormous waste of resources - financial and otherwise. Unfortunately, there are those amongst us who are behaving like hogs at the trough and who will most assuredly lead us either to restricted practice or minimal reimbursement: most likely the latter. It would serve us all well to remember the old adage - pigs get fat and hogs get slaughtered."

What you are saying is just a convenient rationalization for bad clinical practice.  

So you get to determine what is bad practice? Just a little condescending don't you think?

Based on this comment and the one below, it appears you have an emotional rather than rational take on this. This is not just about money it is about good care. Yes a 20 year old that clearly has costo-chondritis should not have an echo - there is no question about this and the cardiologists or primary care doctors that order one are very much in the minority. Calling cardiologists that care about their patients 'hogs' is just beneath a professional (which I assume you are). 

Let me ask you a question David, would you not order an echo on a 40 year old patient with recurrent palpatations. How's your ear? Can you reliable hear an secundum ASD? 

BTW if you despise your fellow collegues it could be time for you to take up another profession/trade. 

Dr. Topol,

 

I think rather than ask "do we really need to do 20 million echocardiograms" per year in the United States, it is more appropriate to ask, how appropriate and cost-effective is echocardiography in treating and screening patients in the USA with heart disease or suspected heart disease.  Currently, more than 27 million people in the United States are living with diagosed heart disease, some of these patients, who are ill, may require multiple echoes over the course of a hospital stay, or over the course of the year, while others may not require any echocardiogram in a given year.  There are millions of more patients in the United States who are living with undiagnosed heart disease, who may benefit from having an echocardiogram.  Echo is the most utilized, non-invasive cardiovascular imaging modality, and arguably the safest (no-radiation) and most cost effective.  We really need to educate ordering providers on ordering this technology appropriately.  The availability of $8000.00 pocket sized echo devices will only accelerate the use of cardiovascular ultrasound as a replacement for the stethoscope.  All physicians caring for patients with heart disease or suspected heart disease need to familiarize themselves with the 2011 ACC/AHA/ASE Appropriateness Criteria for Echocardiography, which can be found on www.asecho.org.

 

The overuse of echocardiography could be reduced significantly if ordering physicians would familiarize themselves with the Appropirateness Use Criteria document created by the American Society of Echocardiography -http://www.google.com/search?sourceid=navclient&ie=UTF8&rlz=1T4ADRA_enUS369US369&q=appropriateness+of+echo+criteria%2c. Application of these criteria should reduce inappropriate echocardiograms and encourage correct and appropriate use of this cost-effective, non radiation based diagnostic modality.

Ron:

Offense is the best defense and your response was offensive and did not contribute to the discussion in a positive way. I actually love my profession and have had very few days in forty years of practice that I have not been really happy and content with my choice of career.

I do not despise my fellow colleagues. Rather, I despise those dishonest physicians who cynically, manipulate patients, parents and the system to their own financial advantage by performing knee-jerk, poor quality echocardiograms on patients who clearly do not need them. 

My ear(s) are actually excellent. I had the good fortune to be trained by one of the master auscultators of the time and I still can hear things that many of the residents and fellows who pass through my clinic cannot and because of the over-reliance on imaging, will never learn to recognize.

There are obviously many "grey-zone" instances when clinical acumen and sometimes raw"gut-feeling" and intuition propel one to make the decision to obtain an echocardiogram and that is no sin. Especially when you are proven right. One must however, resist the temptation to confuse what is essentially cupidity for prudent clinical practice.

  Let me inject a point of view of an engineer. I want to widen the scope of this conversation by bringing in a rather fundamental question: what part of physician's thought process can be (and probably shall be) automated? A good doctor would have skills, of course, to cut through a lot of noise and corners to arrive quickly to a near optimal clinical path. Our systemic problem is both - not having enough good doctors as well as providing incentives to extinguish the remaining ones. In the same time, and I am surprised that the argument is not very clearly stated above, - there is absolutely no way that we can continue to fund current medical system. There will NEVER be enough money in the system because there will never be agreement how much is a good price for letting a person pass away. Interestingly enough, the system knows the price of life and does indeed limits the care, but it tends to limit good care while letting the wild overruns to take place.

Back to algorithms. There were days when I reviewed 1000+ electrocardiograms - an enourmous job. I did it by creating algorithms that were capable of narrowing the field for me to something I could easily manage. CPU cycles are free in comparison with human labor, especially if it takes 20 years to train a good doctor. So, can we automate the process in such a way that screening is done by machines while technicians take care of extreme cases and physicians receive only what really needs to be dealt with? I can hear an objection around difficulty of creating such algorithmic systems, but I counter this with saying that if we cannot really describe what physicians are doing, then we are simply in the age of shamanism. Of course, I am provoking, because many distinguished parctitioners shared with me, at least, privately that they CAN imagine effective machines given that we invest in measurement information collection, and algorithms. Futuristic? Probably, but we are only starting on this path, and it goes slower than we like because we still did not work out a business model for healthcare. A better question to ask: do we already have technologies that we can either adopt or perfect to help this development? We have a lot of them waiting. I also think that doctors shall be instrumental in developing algorithms and systems. Currently, most doctors work as rednecks (no offense meant!) - digging a lot of dirt, often in the dark and under pressure. It is a much better application of the skills if doctors take care of cognitively loaded procedures (e.g. surgeries) and help program computers "to see" patients 365/24/7 for the cost of one checkup visit per year.

ICAEL accreditation requires of the technical director QA sampling of appropriate indications for each echo modality.  I have taken it a step further and reviewed the entire log from 2010 in my lab (just under 13,000 studies).  These were compared to the ACC Appropriate Use Criteria.  Inappropriate indications were less than 1% and marginal indications were ~2%. 

If the indications are correct...perhaps the patient selection is incorrect?

Example:  Complete Echocardiogram w/ bubbles for patient with CVA.  At first glance this sounds appropriate.  Lets broaden the picture - 96 yo with Alzheimer's and GI bleed.  Regardless of the echo findings, what are you going to treat?  I doubt you will send the pt for PFO closure.  Aortic stenosis / aortic root calcification....not an operative candidate.  LV / LA thrombus...not a candidate for anticoagulation.

I contend that health care reform cannot be accomplished without first attaining some level tort reform.  Until physicians can practice unfettered by legal paranoia, CYA is the indication of the times!

Seeing as there is no possible way. because of infinite variations in technician training and meticulousness as well as patient age, size and gender, to standardize electrode placement, to name just a few problems that can cause ECG's to be potentially inaccurate. The ECG is at its best when only there are disorders of rhythm or in the presence of the most severe forms of pathology and the algorhythms that are currently employed in commercially available ECG machines provide interpretations that are probably wrong at least 40% of the time. I have seen many examples of serial ECGs on the same patient, sometimes with the leads never having been removed from the patient having diametrically opposite variations in diagnosis or children and teenagers whose ECG's have been diagnosed by computer and signed off by the reading physician to have LVH that was disproved by echocardiography - an instance where we are frequently forced to do unnecessary echocardiograms . The essential differentiating factor is the experience of the person reading the ECG and until AI is perfected to the point where an affordable "Watson-like"computer can be programmed and miniaturized, the current set of algorhythms is, in my opinion, useless and potentially dangerous. So, from an engineering, cost-analytical viewpoint, you may be correct in your assessment of potential savings but in reality and in good medical practice this does not hold true.

Do you have any idea about how many echos are ordered and done in internists office, as compared to in a cardiologist office. Why haven't you or your societies done anything to limit their capabilities?! What have you done to limit these costs?!

It is not that physicians are not familiar with the criteria. Many ordering cardiologists request repeat studies as soon as the insurer will pay for one. So, every year the patient with mild AS and unchanged physical exam and symptoms gets an Echo because it keeps the machine busy and generates revenue. The insurers usually react by cutting reimbursement for everyone which then generates further over utilization.

Please do point out where my comments were offensive. Instead of throwing abuse back my way you may wish to address the issues I brought up. The health system in the US is a world wide joke. It can't even care for a reasonable proportion of the population. The premise of this discussion is to cut back on services - I fail to see how the US will be a better place after this. 

 

Echocardiograms are used by non cardiologists as a tool to generate income. Internists, general practitioners, vascular surgeons and even podiatrists (yes, podiatrists) and others frequently perform and "interpret " echocardiograms. If one would limit the test to the board certified professional, you would cut the number instantly.

Perhaps if there was no conflict of interest: if cardiologists did not receive any financial benefit for doing extra tests, there would be a substantial reduction in ordering: not just of echos but many other tests. In addition, if doctors had to inform patients of the cost beforehand, and patients had to pay even part of the cost, rather than insurance coing so for most, there would be a reduction. One of the problems is that North American physicians have been educated in a system where organising "educational consultations" in teaching hosptials enriches the departments, and has become part of the culture. So young doctors have learned that rather than thinking, one should simply order tests. In other parts of the world, the senior residents take pride in being able to handle most of the problems themselves, and only refer when really needed. Perhaps American medicine should learn from the rest of the world.

May be we would test less ans "think" more if the lawyers would get off our backs.

I think you need to improve your stethoscope skills if you need an echo to rule out structural heart disease in patients with normal clinical examination and a normal ECG. If you are replacing your physical examination (including stethoscope) with echo, then I agree you need to echo all your patients.

I would be interested to know if you have picked up a clinically relevant abnormality on echo that wasn't detected clinically and that changed your patient management.

CS

I think it is naive to think the stethoscope can do as good a job as even the best pair of ears. ASDs are a classic sample. Grading a lesion is not reliable by ausculatation cf a good echo. I could go on and on and on. Would you really not get an echo if the patient had unexplained SOB? Good luck with that in court. Many a three piece suit specialist was very comfortable in their steth skills until echo came along a made a mockery of them.

It's sad to see that a modern country like the US is advocating a romantic regression to 19th century techniques/guesswork. 

I think you need to retrain in echo. 1/1000. really? PFO's, SBE, LV dysfunction with apical thrombus. 1/1000? Seems like some parallel universe.

So many excellent comments and diverse perspective expressed here (engineers, hospitlaists, neurologists, etc!). True that the cardiologists don't order a lot of the echocardiograms, but they read them and can control the flow. Moreover, the opportunity to rotuinely use a screening echo tool (pocket) during out-patient visits and hosptial rounds to reduce TTEs is not being pursued. Thanks for the input....keep 'em coming!

I think Eric is addressing the issue of echo abuse (don't mean to put words in your mouth Eric but I think the comments gotten a little off that topic.)

1. yes every single human being who has a stroke needs an echo. LOTS OF TIMES I've seen patients with a PFO with no other etiology of stroke. Yes that would change my recommendation. Yes, with rampant coronary artery disease and LV dysfunction, I've found many  apical thrombi or once a large akinetic inferior wall segment in which TEE confirmed the etiology of thrombus there.  LAE (left atrial enlargement) auggests a propensity for atrial fibrillation. I'd probably holter the patient as an outpatient even if the telmetry was negative. ATrial fibrillation is sneaky and intermittant so it's worth a look especially in someone with a large left atrium.  RV dilitation suggest sleep apnea. I could go on for pages and pages. 

2. Have to be careful about NOT ordering an echo in a patient with a change in status. I almost did not order an echo a few months ago in someone who just had one a few months previously. Good thing I did as their EF had plummeted and I did NOT asuculatate a gallop rhythm.  

So, I do LOTS OF FREE ECHO's. Our techs tell us if you have had no change in diagnosis or symptoms, we can't get reimbursed. If the patient with shortness of breath is MORE short of breath than usual, I re do the echo KNOWING I WILL NOT GET PAID because the patient will benefit.  Suprise significant elevations in RSVP, worsening MR and even sudden worsening in moderate aortic stenosis are not all that uncommon. 

I never wish to abuse the system, but I'm far more worried about the system abusing my patient. I have an excellent tool to help my patient get more prescise direction of care. I order echo's whenever I feel they are appropriate when it might change my course of care and let the chips fall where they may. However, I also loathe laziness that leads to too much echo work. Simply not opening the chart and not realizing the patient just had one and going ahead and reordering  (and with NO CHANGE in their cardiovascular status) is inappropropriate. It's often because someone didn't take the time to click on the cardiology section of the EMR to see when their last echo was performed. 

Melissa

The disclosure button is crazy tonight:  I have no disclosures.

Melissa

This - "So you get to determine what is bad practice? Just a little condescending don't you think?" for example is offensive and so is this -  "BTW if you despise your fellow collegues it could be time for you to take up another profession/trade.".

By not addressing what is clearly and egregious over-use of a technology that often is of zero diagnostic value is clearly defensive and missing the point as well as not adding to the discussion to help prevent a situation where the use of echocardiography will be strictly and probably badly regulated.

- I completely agree with this point of view; for a clinical cardiologist doing NOT a TTE  is almost like not doing the physical examination or measuring the blood pressure; clinically indicated TTE nearly always gives you useful information;  not doing TTE could lead to late diagnosis, and maybe mountainhigh costs.

- In general I have some doubts about the usefullness about stress-echo.

- Making  complex algorythms is often as much time-consuming (and money-consuming) as going straight-forward for quick diagnoses (even with incidence of 5%);

- let us never forget that ultrasound is also a technology for the future, given its low invasiveness, low aggressivity, lack of radiation exposure, lack of toxicity, its ecological excellent balance (in contrast with nuclear, radiological and other devices...., also low energy consumption....); going to a future with a need for huge cuts in energyneeds and other resources, ultrasound is definitely a technique that will help survive mankind to the next centuries, while adding useful and quick information that immediately changes clinical and therapeutical planning.

It is funny to read all these comments.  It is fairly clear why physicians in general are easy fodder for politicians.  We spend so much time denigrating each other, we can't band together to come to some consensus.

Having said that, I can't imagine any cardiologist who wouldn't agree with the statement that echocardiograms in general are overutilized.  I've seen instances where patients with known chronic heart failure, with known EFs of 10-20% have a repeat echo when they are readmitted.  I've always asked what new information could one glean from that echo, unless for some reason, other pathology was suspected.  

What needs to be examined are the reasons why echocardiograms or stress tests for that matter, are ordered.  I believe that there are multiple reasons for ordering these tests and some are not in the hands of physicians.  Clearly, there is financial incentive for ordering echos, but that is one of the problems and the only one that Dr. Topol's comments address.  What about the FACT that we live in a litiginous society where a missed diagnosis could be very costly, strictly speaking in financial terms?  An echo is a safe, easy modality that provides much information, even if it's done to "rule out" possible disease states.  If a diagnosis is missed because an echo is not done, it's very difficult to explain why such a ubiquitous modality was not utilized.  I understand we were trained to think and make judgments, but the reality is in today's world, we aren't paid to think.  We are paid to diagnose.  Those are two different enterprises.  I'm not saying that I agree or like that we are in this predicament.  I'm saying this is the reality of the situation.  Patients EXPECT an answer, and one that is backed by utilization of tests.  It's not enough for physicians anymore to say, well, "I think based on what you tell me that.."  In order to fix the problem, we also have to fix patients' expectations.  Until that changes, any test, including echocardiograms, will be overutilized.

20 mln eco in year - is great number.  I am from Russia, I think that we have the same problem.  I do echo for 20 years and fighting with clinicians for good order for echocardiograms. But as usual we have not simple decision in that.  We do not have optimal - gold rule to solve the problem.  what about prenatal and pediatric echo - we need almost  screening program.  Hand - carried US (esp. Echo) is not decision in unqualified hands. I have not simple answer...

Maybe the question should be... Why are echos so expensive?

For all the pontificating about how important it is to get an echo on anybody with a heart, I hope that the reimbursement falls to what it is worth...probably about $30-$50 for the 5-10 minutes time it takes to read one.  When this is done, we will find out if 20 million exams/year are necessary.  Anybody think that's not true?  Consider this...how many ABI measurements are done in cardiologists office each year? I'd be surprised if it were 10% of the echo volume even though it is a good test to find atherosclerotic disease and takes only about 5 minutes to do and interpret.  Why? Because it is not a separately reimbursable as echo's are.  There are the "ggod" reasons and the "real reasons for testing

Bobby

Let me preface with, "I'm just a med student." 

 Of all the comments up, this was the best showing how a real doctor should be thinking, at least in my opinion...

 

So, I do LOTS OF FREE ECHO's. Our techs tell us if you have had no change in diagnosis or symptoms, we can't get reimbursed. If the patient with shortness of breath is MORE short of breath than usual, I re do the echo KNOWING I WILL NOT GET PAID because the patient will benefit.  Suprise significant elevations in RSVP, worsening MR and even sudden worsening in moderate aortic stenosis are not all that uncommon. 

I never wish to abuse the system, but I'm far more worried about the system abusing my patient. I have an excellent tool to help my patient get more prescise direction of care. 

Regardless of how many years from now of practice I have with my steth, I don't think I'll ever be amazing with it like docs were in the past for a combination of reasons. 1. I've never been explicitly taught how to use it...I think the first time that I really was was at the END of my third year in a county hospital when we had rounds for an hour 3 times a week just auscultating. But, 2. there's no longer much of a point. I think every attending I've worked with has told me this in some shape. Saying, "Well, I heard it..." doesn't stand up in court; unless you're like me and record every heart sound on his steth. :D Which, no one will...(how does one "document" an mp3 into a note?)

I forgot what my point was...but I'm sure it is somewhere above. Or not.