Health care reimbursement in the United States is undergoing a significant shift from fee-for-service to value-based payment with the use of models based on bundles, episodes of care, and outcomes. Within this shift, challenges and opportunities exist for the field of cardiovascular ultrasound regarding how to define and provide high-quality diagnostic imaging that may be more directly linked to patient outcomes. Wiener observed that it is easier to measure the volume of cardiac imaging than its value, which typically focuses on how imaging affects patient care. During the American Society of Echocardiography Foundation Value-Based Healthcare Summit, it was noted that a challenge in defining cardiovascular ultrasound value is the existence of an often indirect link between the diagnostic test and patient outcomes. In addition, although a positive finding may lead to direct therapeutic intervention, the effect of negative test results that may eliminate or narrow differential diagnoses is harder to evaluate and may not always be considered when judging the value of cardiac imaging. Because of these challenges, quality efforts have traditionally focused on the procedural aspects of echocardiography.
The American Society of Echocardiography advocates several measures to ensure a high-quality echocardiographic examination. These measures include, among others, adequate ultrasound equipment, competent technical skills, and consistent and complete image acquisition. As a result, study completeness is considered an essential component of a high-quality echocardiographic examination. Standard imaging protocols encompass the integration of two-dimensional, color, and spectral Doppler modalities to provide comprehensive evaluation of cardiac disorders. However, a variety of additional images beyond the standard protocol may be needed for any given patient, so the protocol should be considered minimum criteria that may be inadequate without supplementation.
Despite the imaging standards that have been proposed, incomplete echocardiographic studies still appear to be an issue. Recently, Nagueh et al . noted that one of the most frequent deficiencies resulting in delayed Intersocietal Accreditation Commission Echocardiography accreditation was incomplete studies that did not include required imaging components (32.7% of 2,020 laboratories). Furthermore, when Benavidez et al . examined diagnostic echocardiography errors at a large academic pediatric cardiac center, incomplete studies were noted to be a factor in 14% of diagnostic errors. Previous findings by these investigators documenting a higher rate of diagnostic errors in the postanesthesia care unit caused a practice change in that area; a new process was implemented with discussion of an imaging plan between supervising cardiologist and sonographer, then immediate study review and acquisition of more images as required. Data from the most recent study indicated that studies performed in the postanesthesia recovery area were no longer significantly associated with diagnostic errors. Although causation cannot be proved, it appears possible that prompt review of examinations in the postanesthesia care unit may have contributed to a decrease in the risk for diagnostic errors in this particular clinical setting.
In this issue of JASE, Johnson et al . introduce a quality improvement (QI) initiative exploring whether physician review of first-time echocardiographic examinations in an outpatient pediatric echocardiography laboratory improved study completeness. Studies were considered complete and included in the analysis if all anatomic structures were evaluated by means of diagnostic quality images. Data from studies with predismissal review (QI scans) were obtained prospectively and compared with studies performed before the implementation of predismissal physician review (control group).
The patient population was similar between groups with regard to age, height, weight, and technical barriers to study completion (patient motion or agitation, poor acoustic windows, or inability to reposition the patient). In the control group, 35% of studies were considered incomplete. Similar results (32% of studies considered incomplete) were found in the QI group before physician review. After the acquisition of additional images by the sonographer, physician, or both, only 6% of QI studies were considered incomplete ( P < .001). Median scan time was 36 min in the control group and 44 min in the QI group before study review. Review and acquisition of additional images added a median of 6 min per study (range, 1–28 min) in the QI group.
Sonographer perception of the intervention was evaluated through an anonymous survey. The majority of sonographers believed that predismissal review affected communication with the interpreting physicians in a very or somewhat positive manner. “Job satisfaction” was not defined by the authors, but was believed by 50% of sonographers to be positively affected. Interestingly, 74% of sonographers believed that their performance did not change, despite the increase in median scan time between the control group and the QI group.
The investigators concluded that review of initial outpatient echocardiograms before patient discharge significantly improved study completeness, while adding minimal time to total study duration. Furthermore, it was believed that predismissal review improved sonographer-physician communication and potentially prevented unnecessary testing and increased cost of care.
Limitations of this study include the pitfalls of retrospective data analysis. As the investigators noted, potential barriers to study completion and any communication between sonographer and physician were not documented for studies in the control group. Therefore, it is not possible to know how these factors influenced the percentage of incomplete studies. In addition, interrater reliability was only moderate, with 80% agreement (κ = 0.55, P = .02). However, approximately the same percentage of studies in the QI group was considered incomplete before physician review, so it would appear the two groups were comparable.
There were also limitations in the survey component of this study. The survey questions provided do not include definitions of terms such as “performance” and “job satisfaction.” Lack of clear definitions may lead to variable interpretation of each term by survey respondents and may ultimately provide data that do not measure what is desired. In addition, it is unclear whether reliability testing of the survey tool was performed before its use. Finally, only sonographers were surveyed; therefore, data detailing physicians’ perspectives of the project were not available.
Johnson et al . noted that delayed or inaccurate testing may lead to further unnecessary testing or adverse outcomes. In this study, one patient in the control group was hospitalized and underwent additional echocardiographic testing for a presumed left atrial mass, which was later determined to be an artifact. No patients in the QI group required additional testing. Because there was no further testing, and because it is unclear whether patients were lost to follow-up during the subsequent 12-month period, it is not possible to truly determine the rate of diagnostic error due to incomplete testing.
It may be helpful to examine the experience of additional centers that practice predismissal review, as this concept is not new and is used for both pediatric and adult echocardiography. The Seattle Children’s Hospital pediatric laboratory outpatient practice does not require predismissal review, although a physician interpreter is readily available in case of questions or concerns. Indeed, having access to interpreting physicians appears to help focus outpatient examinations. A pre-examination huddle involving the sonographer, clinic physician, and interpreting physician clarifies the data needed to answer the clinical question. Subsequently, pre–patient dismissal interpretation of outpatients is an option, but not the rule. A similar process has been applied to complex inpatient examinations, which are typically more goal directed than outpatient examinations. A “check-in and check-out” system is used, in which the sonographer “checks in” with the interpreting physician to gain understanding of the views that are to be obtained, then “checks out” via phone from the patient’s room. At this point, the physician may perform a preliminary interpretation and ensure that all required data were obtained. Anecdotally, this process is believed to significantly reduce the frequency with which sonographers return to the bedside to obtain additional data.
Historically, most outpatient adult and pediatric echocardiographic studies at Mayo Clinic Rochester are interpreted before patients leave the laboratory, which is believed to be helpful given the wide range of complex pathologies encountered at this tertiary referral center. In addition, real-time review of studies and the attendant immediate feedback contribute to an optimal learning environment for sonographers, sonography students, and cardiovascular fellows. The study by Johnson et al . excluded patients who had truncated examinations because of patient motion or agitation, poor acoustic windows, or inability to reposition the patient. However, in both the adult and pediatric echocardiography laboratories at Mayo Clinic Rochester, predismissal review is considered especially helpful when barriers to acquiring a complete study are present, as the interpreting physician may guide additional critical image acquisition on the basis of individual circumstances.
Over time, increasing demand for Mayo Clinic echocardiographic services made predismissal review of images challenging to maintain. Therefore, qualified sonographers were trained through informal didactic and on-the-job clinical education to serve in an advanced practice role, working in tandem with physicians and staff sonographers to verify that all necessary data were obtained for all patients before departure. The advanced cardiovascular sonographer (ACS) is not an independent practitioner but performs preliminary assessment of the study under direct supervision of interpreting physicians. The ACS then provides or directs additional image acquisition as required to ensure complete studies, often in complex and technically difficult imaging situations. In addition, this model appears to facilitate improved patient flow and promote a more optimal educational environment, as physicians in particular may be able to spend more time teaching in the clinical area. More recently, formal ACS educational programs and an ACS credentialing examination have been developed as proposed by Mitchell et al .
The field of echocardiography has progressed dramatically from the days of B-mode and M-mode imaging. In the current era, should the practice of predismissal interpretation become the norm? On one hand, predismissal review requires the on-site or readily available presence of interpreting physicians, which may be difficult for some facilities to provide. On the other hand, predismissal review provides an opportunity for a “second set of eyes” to evaluate sometimes difficult images from complex studies using complex technology. In the adult echocardiography world, where patient obesity is increasingly prevalent, predismissal review may also provide a “second set of hands” for difficult-to-image patients. This factor is especially important given concerns regarding sonographer work-related injuries ; increasing work flow efficiency and minimizing hands on scanning time should be a principal goal.
The development of advanced echocardiographic modalities such as real-time three-dimensional echocardiography and speckle-tracking analysis of myocardial mechanics, in addition to imaging during percutaneous interventions, requires a greater knowledge base and technical skill on the part of sonographer and physician than ever before. Minimum standards have been defined for cardiac sonographers, and sonographers are expected to expand the echocardiographic examination as necessary to answer the clinical question posed for each patient. However, entry-level sonographer education is not uniform; educational standards and accreditation statuses vary by program, and not all health care facilities require sonographer credentialing. Even for credentialed sonographers, varying levels of skill, speed, and experience may be present. Many long-time sonographers were trained on-the-job and gained knowledge and skills along the way (these authors included). This may be particularly true for pediatric sonographers, as formal pediatric echocardiography program accreditation has only recently become available, and there are only four accredited programs in the United States. Anecdotally, sonographers performing pediatric echocardiography at some high-volume centers may more easily develop advanced skills, as they scan complex congenital anomalies day in and day out. Regardless, variation in adult and pediatric sonographer technical skill almost certainly exists.
Many highly qualified sonographers provide complete studies and readily recognize when specific findings should be brought to the attention of the interpreting physician before patient dismissal. In laboratories staffed by skilled sonographers, predismissal review may be of less value, as the percentage of incomplete examinations may be quite low. It is also valid to question whether the extra time added for each patient in this setting is worth the benefit when predismissal review does not result in additional reimbursement.
In laboratories with junior or less skilled sonographers, predismissal review may enhance the completeness and quality of examinations. In the study by Johnson et al ., sonographer credentialing status, individual skill, and experience were not delineated, therefore it is not known whether there was a relationship between sonographer skill level and incomplete examinations. The question may be worth exploring, as those data could support prioritization of predismissal review for less experienced or less proficient sonographers. In that scenario, predismissal review may also provide a learning environment in which additional skills and knowledge may be gained.
Johnson et al . noted predismissal review not only improved study completeness, but resulted in improved sonographer-physician communication and sonographer job satisfaction. Indeed, the improved job satisfaction reported in this study may be derived from sonographers’ gaining clear knowledge of the task to be completed, with physician support provided as necessary. One sonographer in this study reported decreased job satisfaction; it is possible some sonographers may perceive implementation of predismissal review as a negative reflection of their skill levels, whether or not technical skill is truly an issue.
Value-based reimbursement is knocking on our door; health care administrators and providers must change focus from volumes to value. It could be argued that one definition of high-value imaging is the provision of a complete diagnostic study that answers the clinical question. From our perspective, echocardiography is a team sport. Predismissal review by a skilled senior sonographer, ACS, or physician may provide one avenue for demonstrating the quality of echocardiography by guiding additional imaging, facilitating the correct diagnosis, minimizing diagnostic errors, and avoiding unnecessary downstream testing and procedures. If reviewing studies before patient dismissal results in complete, higher quality diagnostic data that definitively answer the clinical question, then this may be a strategy worth pursuing.
Dr. Bremer is president of the Intersocietal Accreditation Commission Echocardiography Board of Directors, director of the ACS Program at the Mayo School of Health Sciences, and a member of the Cardiovascular Credentialing International ACS Credentialing Exam Committee. The opinions expressed by Dr. Bremer in this article are her own and should not be attributed to the Mayo Clinic.