Table of Contents
Value-Based Healthcare in the United States 756
The Value Choice in Cardiac Imaging 757
Echocardiography’s Value in Clinical Care 758
The Patient Perspective 761
Payer Perspectives on Value-Based Healthcare 762
The Value of Echocardiography in Research 764
Breakout Sessions 766
Summary 769
For the past decade, the healthcare system in the United States has been undergoing a seismic shift in models of care and payment paradigms. Until recently, nearly all medical care in the United States was reimbursed on a “fee-for-service” basis, as doctors and hospitals were paid separately for each test or procedure they performed. In 2006, Michael Porter and Elizabeth Teisberg introduced the value agenda in their seminal book Redefining Health Care and noted in a 2007 article that physician leadership was essential to bringing about meaningful changes and improving value in healthcare. Since that time, both government and private payers have begun paying for care in a multitude of new ways, such as bundled payments, episode-of-care payments, and outcomes-dependent payment models. This shift from “volume to value” represents both a challenge and an opportunity for the field of cardiovascular ultrasound.
On September 12, 2014, the American Society of Echocardiography (ASE) Education and Research Foundation hosted Value-Based Healthcare: Summit 2014 in Washington, D.C. This event was organized around three main goals:
- 1.
To create a dynamic forum for discussion of the evolving value-based healthcare environment and the important role of cardiovascular ultrasound in that environment.
- 2.
To disseminate important information to a wider audience through publication of the Summit proceedings in the Journal of the American Society of Echocardiography .
- 3.
To provide a “living resource” for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound.
This Summit featured speakers and panelists from across the healthcare spectrum, each offering a unique perspective on the transition to value-based healthcare, with a focus on the role of cardiovascular ultrasound. Clinicians, legislators, private and governmental payers, patient advocates, researchers, and industry representatives came together to discuss ways to deliver superior value in cardiovascular care in this rapidly changing healthcare environment.
The Summit was organized into panels offering a variety of perspectives on value-based healthcare and the role of cardiovascular ultrasound in both the current system and the new paradigm. The various panels focused on five key aspects of the discussion: value-based healthcare in the United States, the value choice in cardiac imaging, the value of echocardiography in clinical cardiology, payer perspectives on value, and the value of echocardiography in research. Finally, Summit attendees participated in three breakout groups to explore specific trends in healthcare and cardiac imaging. Participants discussed the role of cardiovascular ultrasound in the current landscape, as well as challenges and opportunities waiting in the future. The following sections summarize the key points of discussion, recommendations, and selected readings for further information.
Value-Based Healthcare in the United States
Panelists: Representative James H. S. Cooper, JD (D-TN), Thomas R. Graf, MD, Benjamin F. Byrd III, MD, FACC, FASE, and Randolph P. Martin, MD, FACC, FASE, FESC
A Congressional Perspective
Representative Cooper opened the Summit by discussing the growth in healthcare expenditures in America and the challenges of addressing this issue through legislative action. He emphasized that today’s healthcare system is in transition, characterized by rapid change in insurance regulation as well as healthcare delivery, the decline in private practice and a concomitant rise in hospital employment of physicians, and growing out-of-pocket health expenditures for consumers. Representative Cooper addressed three key questions regarding value-based healthcare: (1) What is value-based healthcare? (2) Who should determine value? and (3) Will value-based healthcare work?
From a practical standpoint, for the average patient, the simple definition of value-based healthcare is “getting your money’s worth.” Although Americans are excellent shoppers, Representative Cooper noted that they have never truly been allowed to shop for their healthcare until recently. The complex insurance system and widespread use of employer-sponsored healthcare tend to hide the true cost of care from the average patient, but that is changing with the advent of insurance exchanges and the shifting of costs from employers to individuals.
Representative Cooper strongly urged doctors and their professional associations, in conjunction with patients and patient groups, to take the initiative in defining value. Medical professionals are key to the decision-making process, because they have a deep understanding of the benefits of specific procedures. Patients want to make choices in their own best interest. Importantly, the medical profession must regulate itself continually to avoid waste and fraud, or the government may be forced to take the decision out of their hands.
Finally, the short answer is that value-based healthcare has to work; there is no real alternative, because the current level of expenditures is not sustainable, either by the government or by consumers. There has never been a greater moment for cardiology leadership to foster progressive efforts in lifestyle changes among the broader population, as well as to shape the future of healthcare delivery.
A Health System Perspective
Speaker Dr Thomas Graf offered a unique perspective as a family medicine physician who also oversees population health efforts at Geisinger Clinic, one of the more successful health systems in implementing new models of care such as accountable care organizations (ACOs). Dr Graf emphasized that the objective of tomorrow’s healthcare delivery system should focus on the “Triple Aim plus.” The Triple Aim is to achieve higher quality for populations, better patient experience of care, and lower costs. In addition, however, Dr Graf also emphasized the need to achieve a better professional experience for healthcare providers.
Dr Graf described in some detail the conceptual underpinnings of the ACO model. The ACO model combines the organizational structures of a health plan with those of a clinical enterprise, and it is critical that each organizational component do what it does best: that the health plan function primarily in the realms of population health analysis, finances, marketing, and alignment of reimbursement incentives, while the clinical enterprise focus on care delivery, best practices, quality improvement, and patient and family involvement. Overall, both components should focus on prevention and early intervention services to reduce the likelihood that manageable conditions will become chronic, the effective management of the nearly 50% of Americans with chronic conditions who are responsible for 84% of US healthcare expenditures, and the elimination of fraud and waste. At least for now, effective ACO operation involves balancing a fee-for-service mind-set with ACO goals, which means reducing length of stay, readmissions, the use of postacute care, and inappropriate use of ancillary services, including imaging.
Dr Graf presented a new methodology for ensuring the appropriateness of cardiovascular imaging for coronary artery disease (CAD), which has been implemented at Geisinger and has proven highly effective. Under the new system, each CAD imaging referral is referred to a pool of CAD imaging referral nurses, who conduct a full chart review, which is tested against a test protocol, with cardiologist input. The cardiologist selects and signs the order for the optimal test: essentially, “precertification” is managed by the cardiology department. After the test is performed, the results are communicated to the ordering provider. Under this protocol, the percentage of patients who underwent second CAD imaging tests within 90 days dropped from 20% to 10%, and the protocol resulted in an 11.1% reduction in CAD tests overall ( Table 1 ).
| Group | Second test in 90 days | Test savings in 694 consecutive patients |
|---|---|---|
| GHP | 20.1% | Baseline |
| GHS PCP | 14.2% | −46 tests (5.9% reduction overall) |
| GHS PCP with CAD imaging | 10.0% | −87 tests (11.1% reduction overall) |
Dr Graf outlined several important lessons that Geisinger has learned over the years as it has transitioned to population health–based care. The first crucial lesson is that improving the reliability of the process of care is equally as important as knowing what treatment to provide; the system must enable delivery of the optimal treatment to every patient every time. Electronic tools such as electronic health records are successful only when implemented into a system of care that has been efficiently designed. Finally, compensation can help focus attention on a specific issue, but it is not sufficient to truly drive change.
Value-Based Healthcare in the United States
Panelists: Representative James H. S. Cooper, JD (D-TN), Thomas R. Graf, MD, Benjamin F. Byrd III, MD, FACC, FASE, and Randolph P. Martin, MD, FACC, FASE, FESC
A Congressional Perspective
Representative Cooper opened the Summit by discussing the growth in healthcare expenditures in America and the challenges of addressing this issue through legislative action. He emphasized that today’s healthcare system is in transition, characterized by rapid change in insurance regulation as well as healthcare delivery, the decline in private practice and a concomitant rise in hospital employment of physicians, and growing out-of-pocket health expenditures for consumers. Representative Cooper addressed three key questions regarding value-based healthcare: (1) What is value-based healthcare? (2) Who should determine value? and (3) Will value-based healthcare work?
From a practical standpoint, for the average patient, the simple definition of value-based healthcare is “getting your money’s worth.” Although Americans are excellent shoppers, Representative Cooper noted that they have never truly been allowed to shop for their healthcare until recently. The complex insurance system and widespread use of employer-sponsored healthcare tend to hide the true cost of care from the average patient, but that is changing with the advent of insurance exchanges and the shifting of costs from employers to individuals.
Representative Cooper strongly urged doctors and their professional associations, in conjunction with patients and patient groups, to take the initiative in defining value. Medical professionals are key to the decision-making process, because they have a deep understanding of the benefits of specific procedures. Patients want to make choices in their own best interest. Importantly, the medical profession must regulate itself continually to avoid waste and fraud, or the government may be forced to take the decision out of their hands.
Finally, the short answer is that value-based healthcare has to work; there is no real alternative, because the current level of expenditures is not sustainable, either by the government or by consumers. There has never been a greater moment for cardiology leadership to foster progressive efforts in lifestyle changes among the broader population, as well as to shape the future of healthcare delivery.
A Health System Perspective
Speaker Dr Thomas Graf offered a unique perspective as a family medicine physician who also oversees population health efforts at Geisinger Clinic, one of the more successful health systems in implementing new models of care such as accountable care organizations (ACOs). Dr Graf emphasized that the objective of tomorrow’s healthcare delivery system should focus on the “Triple Aim plus.” The Triple Aim is to achieve higher quality for populations, better patient experience of care, and lower costs. In addition, however, Dr Graf also emphasized the need to achieve a better professional experience for healthcare providers.
Dr Graf described in some detail the conceptual underpinnings of the ACO model. The ACO model combines the organizational structures of a health plan with those of a clinical enterprise, and it is critical that each organizational component do what it does best: that the health plan function primarily in the realms of population health analysis, finances, marketing, and alignment of reimbursement incentives, while the clinical enterprise focus on care delivery, best practices, quality improvement, and patient and family involvement. Overall, both components should focus on prevention and early intervention services to reduce the likelihood that manageable conditions will become chronic, the effective management of the nearly 50% of Americans with chronic conditions who are responsible for 84% of US healthcare expenditures, and the elimination of fraud and waste. At least for now, effective ACO operation involves balancing a fee-for-service mind-set with ACO goals, which means reducing length of stay, readmissions, the use of postacute care, and inappropriate use of ancillary services, including imaging.
Dr Graf presented a new methodology for ensuring the appropriateness of cardiovascular imaging for coronary artery disease (CAD), which has been implemented at Geisinger and has proven highly effective. Under the new system, each CAD imaging referral is referred to a pool of CAD imaging referral nurses, who conduct a full chart review, which is tested against a test protocol, with cardiologist input. The cardiologist selects and signs the order for the optimal test: essentially, “precertification” is managed by the cardiology department. After the test is performed, the results are communicated to the ordering provider. Under this protocol, the percentage of patients who underwent second CAD imaging tests within 90 days dropped from 20% to 10%, and the protocol resulted in an 11.1% reduction in CAD tests overall ( Table 1 ).
| Group | Second test in 90 days | Test savings in 694 consecutive patients |
|---|---|---|
| GHP | 20.1% | Baseline |
| GHS PCP | 14.2% | −46 tests (5.9% reduction overall) |
| GHS PCP with CAD imaging | 10.0% | −87 tests (11.1% reduction overall) |
Dr Graf outlined several important lessons that Geisinger has learned over the years as it has transitioned to population health–based care. The first crucial lesson is that improving the reliability of the process of care is equally as important as knowing what treatment to provide; the system must enable delivery of the optimal treatment to every patient every time. Electronic tools such as electronic health records are successful only when implemented into a system of care that has been efficiently designed. Finally, compensation can help focus attention on a specific issue, but it is not sufficient to truly drive change.
The Value Choice in Cardiac Imaging
Panelists: R. Parker Ward, MD, FACC, FASE, FASNC, Thomas J. Ryan, MD, FACC, FASE, and James D. Thomas, MD, FACC, FASE
This session of the Summit explored two aspects of cardiovascular ultrasound’s place in the evolving economics of healthcare: first, how volume and costs of cardiovascular ultrasound have been controlled since 2008, and second, how echocardiography laboratories and physicians must change practices to thrive in a value-based system delivery system.
Dr Parker Ward observed that over the past two decades, US healthcare spending on medical imaging in general, and cardiovascular imaging in particular, has far outpaced healthcare spending on all other medical services. Although echocardiography did not grow as fast as other cardiac imaging modalities during this time period, echocardiography nonetheless remained a contributor as the highest volume cardiac imaging test. This growth rate was perceived as unsustainable, and “uncontrolled imaging” continues to be cited as a primary target in ongoing efforts to curb healthcare spending. However, in recent years, the facts have changed. Since 2008, medical imaging utilization, including that of echocardiography, has been declining. According to a 2015 Medicare Payment Advisory Commission report to Congress, the volume of imaging procedures under the Physician Fee Schedule declined by approximately 7% from 2009 to 2013 (after increasing by 85% from 2000 to 2009). Echocardiographic procedures billed to Medicare under the Physician Fee Schedule fell by 1.8%, 3.7%, 5.1%, and 7.3% annually from 2009 to 2013 on a per beneficiary basis. The reasons for this decline are multiple and incompletely understood. Certainly there has been a reduction in payment for cardiovascular ultrasound services, particularly in the office setting, while some insurance companies have restricted access to cardiovascular ultrasound, sometimes to the detriment of patients.
Beyond these reasons, however, there has been a clear commitment by the medical community to address issues of imaging utilization. The ASE and the American College of Cardiology, along with other specialty societies, have collaborated to publish appropriate use criteria (AUC), which provide guidance for physicians, payers, and patients in the best use of imaging procedures in optimal patient care. AUC are available for a variety of imaging modalities, including transthoracic echocardiography (TTE), stress echocardiography, and transesophageal echocardiography (TEE). The AUC for echocardiography are easily accessible, including a free mobile application from ASE that quickly provides the appropriateness level (appropriate, may be appropriate, and rarely appropriate) for hundreds of clinical scenarios. Several intensive education efforts regarding echocardiography AUC at Massachusetts General Hospital resulted in steep reductions in inappropriate ordering; from 13% to 5% in an inpatient setting, and from 34% to 13% in an outpatient setting. The AUC also allow the identification of potential “missed opportunities,” in which an imaging test that is not performed may have contributed to suboptimal patient care. In a study of inpatients who did not undergo echocardiography during their stays, 16% presented with clinical conditions for which the test would have been appropriate, suggesting that underutilization as well as overutilization of cardiovascular ultrasound should be addressed.
One of the challenges in defining the value of cardiovascular ultrasound is the indirect manner in which any diagnostic test result may affect outcomes. The value of a positive test result that leads directly to a therapeutic intervention and an improved outcome is obvious. However, frequently test results are negative, eliminating a suspected diagnosis or cause of symptoms. This scenario also provides great value by reassuring the patient or caregiver or by prompting additional diagnostic inquiry that may lead to diagnosis and improved outcome. This value is more “indirect” and thus not frequently considered when assessing the value of an imaging test. A recent study from Dr Ward’s medical center found that over a 2-year period, 82% of appropriate echocardiographic examinations had demonstrable clinical impact, which was “indirect” in half.
Panelist Dr Tom Ryan brought the unique perspective of a cardiovascular ultrasound expert who, as chair of the cardiovascular program at The Ohio State University, is charged with the responsibility of ensuring that all cardiovascular imaging modalities are used appropriately in patients’ best interests, without bias favoring one modality over another. As one who must decide where to invest resources to maximize patient outcomes, Dr Ryan made these key points: (1) The way physicians are paid will continue to evolve, (2) growth will no longer be the key to job security, and (3) physicians will not get paid for poor-quality work. Of particular importance is the Bundled Payments for Care Improvement initiative that incentivizes providers to deliver more coordinated care, by placing providers at risk for providing all services associated with predefined episodes of care.
There are a few key maxims for survival in this changing world: (1) Behave as if you are part of a large organization (because you are or will be); (2) do just enough cardiovascular ultrasound, and do it really well; (3) coordinate imaging across modalities, so that you do the best test first; (4) standardize your protocols, adhering to best practice standards; (5) implement AUC so you target the right population; and (6) stratify your service options, so that you use the appropriate level of sophistication to answer the clinical question (e.g., you don’t need three-dimensional strain imaging to rule out a pericardial effusion). The role of hand-carried ultrasound is rapidly evolving; one function will likely be to serve as a triage agent to ensure that an echocardiography laboratory does only the highest yield studies. For echocardiography laboratories, quality will be king, with an emphasis on quantification, reduction in interreader variability, and delivering the best product for the lowest cost in resources. Fortunately, with low fixed and variable costs and the ongoing innovation evident in the field, cardiovascular ultrasound is well suited to compete in the future, whether in a fee-for-service system or one in which providers assume risk for providing value-based care.
Echocardiography’s Value in Clinical Care
One may examine the role of cardiovascular ultrasound in value-based models of healthcare from the standpoint of (1) specific patient populations (2) specific diseases, or (3) how patients themselves perceive value. During the Summit, all three approaches were explored.
Specific Patient Populations
Panelists: Randolph P. Martin, MD, FACC, FASE, FESC, Jack Rychik, MD, Steven A. Goldstein, MD, and Michael H. Picard, MD, FACC, FASE, FAHA
Patients Undergoing Cancer Treatments
Advances in the diagnosis and treatment of cancer have markedly improved survival. The US National Cancer Institute estimates that 13.7 million cancer survivors were alive in 2012 and that this number will approach 18 million by 2022. Some cancer treatments can be complicated by side effects on the cardiovascular system. For example, anthracyclines, trastuzumab, and some tyrosine kinase inhibitors have detrimental effects on myocardial function, and radiation therapy to the thorax can damage heart valves, coronary arteries, and the pericardium. Thus, many survivors are at potential risk for cardiac disability from their cancer treatments. In addition, as successfully treated cancer patients age, they are subject to the same common cardiac diseases as the general population.
There are several roles for cardiovascular ultrasound during potentially cardiotoxic cancer treatment regimens. First, before potentially cardiotoxic chemotherapy, echocardiography can ensure that patients do not already have impaired cardiac function. Second, during chemotherapy, cardiovascular ultrasound can monitor ventricular function for deterioration. Last, during follow-up treatment, cardiovascular ultrasound can determine if new symptoms are potentially due to cardiac disease. Early detection of decreased ventricular function allows modification in the regimen, either by increasing the interval between doses or reducing the total cumulative dose of a potentially toxic agent. There is current enthusiasm for using new echocardiographic parameters such as myocardial deformation or strain imaging to detect subclinical perturbations in ventricular function earlier and more reliably than can be identified by traditional measurements such as left ventricular (LV) ejection fraction. These techniques are being studied to determine if such early detection can result in treatment modifications that maintain high cure rates but prevent the development of clinically important effects on LV function and later cardiac disability.
Reducing LV dysfunction as a sequela of cancer treatment results in less disability, higher quality of life, fewer future cardiac complications, and lower subsequent costs for care. When specific, low-cost echocardiographic imaging protocols are integrated into complex cancer care, the value equation strongly favors cardiovascular ultrasound.
Congenital Heart Disease in the Fetus
In the United States, approximately 30,000 to 40,000 children are born each year with congenital heart lesions, making congenital heart disease the most common birth defect. Ultrasound evaluation during pregnancy with echocardiography is the only means to identify defects of the heart before birth.
Accurate identification of important structural heart defects before birth provides a number of benefits. It allows the development of a plan for pregnancy and for delivery at an expert site that can manage the hypoxia and hemodynamic compromise that may accompany a defect. This strategy allows the implementation of treatment as soon as the infant is delivered and results in the best outcomes, because it can prevent the development of high-risk sequelae such as hypotension, shock, and end-organ damage, including neurologic impairment. Later postnatal diagnosis leads to delayed identification, neonatal instability, long-term complications, and higher mortality. In such cases, there is often a higher lifelong cost of treating these impaired survivors, such as the costs associated with the management of cerebral palsy.
Thus, the value of cardiovascular ultrasound in the assessment of congenital heart defects in the fetus is clear. Its use allows early diagnosis and leads to better outcomes, lower mortality, and a reduction in lifelong healthcare costs.
Patients with Complex Myocardial Infarction (MI)
In the various phases of treatment of MI, time is of the essence. Numerous studies have shown that delays in the treatment of acute MI result in lower event-free survival rates. In patients with confusing presentation, echocardiography combined with biomarkers can improve the accuracy of diagnosis, and in particular, echocardiography can show the location and size of an MI.
In patients presenting with hemodynamic compromise after MI, early diagnosis of the cause of the problem is critical to expedite lifesaving treatment. Studies of patients with cardiogenic shock have shown that there is often a significant time delay in determining the cause of shock, and clinical experience suggests that bedside imaging with echocardiography (both TTE and TEE) can reduce that time delay and thus reduce sequelae such as end-organ damage.
Last, echocardiographic assessment of LV systolic and diastolic function after MI provides prognostic value and assists in personalizing post-MI care. For example, eligibility for certain post-MI treatments, such as the use of implantable cardiac defibrillators, may vary on the basis of the LV ejection fraction measured by echocardiography.
Although many cardiac imaging modalities can provide similar information, cardiovascular ultrasound has advantages and favorable value in MI care because of its ability to image at the bedside and its relatively low cost, wide availability, and rapid information turnaround. Of note, the use of echocardiographic contrast agents is of particular value in MI care, because it improves the accuracy and reproducibility of regional wall motion assessment when image quality is technically limited.
Specific Cardiac Diseases
Panelists: Theodore P. Abraham, MD, FACC, FASE, Linda D. Gillam, MD, MPH, FASE, Pamela S. Douglas, MD, MACC, FASE, FAHA, and Michael H. Picard, MD, FACC, FASE, FAHA
Valvular Heart Disease
Valvular heart disease is common, and its prevalence will continue to increase as the population continues to age. For those aged 18 to 44 years, the prevalence is 0.7%, but for those >75 years of age, the prevalence is 13.3%. Treatment options for the various valvular diseases continue to expand, in terms of both surgical repair and transcatheter techniques. Thus, patient selection is critical, and cardiovascular ultrasound is the foundation of this process. Optimizing clinical management in these patients involves determining both the severity of the valve dysfunction and the mechanism underlying the dysfunction. Cardiovascular ultrasound is comparable and in some situations superior to other imaging modalities in assisting the management of valvular heart disease. In addition to its relatively low cost, wide accessibility, and lack of ionizing radiation, cardiovascular ultrasound provides a comprehensive, real-time assessment of valve anatomy and function, as well as secondary changes in ventricular function, atrial function, and pulmonary artery pressures. Further testimony to its value in this set of diseases is demonstrated by the important place of echocardiography in the current ACC/AHA valvular heart disease guidelines.
Heart Failure
Heart failure places a significant financial burden on our society. There are >5 million cases in the United States, and an estimated 825,000 new cases are diagnosed each year. It is one of the most common discharge diagnoses in the elderly. Cardiovascular ultrasound provides value on many levels in these patients, ranging from those with early symptoms to those with advanced end-stage heart failure. It has multiple important uses: diagnosis through quantitation of systolic and diastolic ventricular function, classification of etiology, assessment of response to therapy, and guidance of advanced treatments. Moreover, as healthcare models move from pay-for-procedure to pay-for-performance, cardiovascular ultrasound maintains its value, because it is relatively low cost, and it is more portable and more widely available than other noninvasive imaging technologies ( Table 2 ). In addition, in contrast to other modalities, it is a scalable technology (with scalable costs) that can be tailored to the patient’s needs, be it a complete diagnostic assessment with a fully equipped machine or a quick check of LV ejection fraction with a handheld device. For example, cardiovascular ultrasound can assist in appropriate triage of patients with heart failure to medical therapy, cardiac resynchronization therapy, or mechanical circulatory assist device therapy, helping ensure that these expensive technologies are used appropriately. Clearly, because of its role in optimizing care and outcomes at an affordable cost, cardiovascular ultrasound is highly valuable in heart failure. It has an important role in determining whom to treat, how to treat, and when to treat.
| Characteristic | Echocardiography | CMR | CT | Nuclear scintigraphy |
|---|---|---|---|---|
| Availability | ++++ | ++ | ++ | +++ |
| Portability | ++++ | — | — | — |
| Cost (relative value units) ∗ | 9.11 † | 22.51 ‡ | 14.39 § | 13.59 || |
| Radiation risk | — | — | ++++ | ++++ |
∗ From the Centers for Medicare and Medicaid Services, National Physician Fee Schedule ( http://www.cms.hhs.gov/PFSlookup/)3_PFS_Document.asp ).
† Sum of relative value units for CPT codes 93303, 93323, and 93320.
CAD Detection
The clinical and economic burden of diagnostic testing to detect suspected CAD is large, with >20 million stress tests performed each year in the United States. The decision making regarding testing begins with appropriateness; the decision to test is an important and necessary precursor to choosing the type of test. It does not end with test performance, however, as the value of a test is only as good as the information it provides and only as good as how that information is incorporated into clinical care.
In her examination of the value of stress echocardiography for detection of CAD, Dr Pamela Douglas used the Triple Aim construct defined by the Institute for Healthcare Improvement. In assessing value, the Triple Aim approach focuses on an intervention’s contribution to personal and population health, the patient experience of care, and per capita cost.
In terms of population health, there are several important considerations: the accuracy of CAD detection by stress echocardiography equals or exceeds the accuracy of other forms of stress tests, stress echocardiography is equally accurate in men and women, and it can be performed whether or not a patient is able to exercise (through pharmacologic methods). Perhaps equally important, stress echocardiography provides additional information regarding heart and valve function—information not provided using other methods—which may assist in identifying the cause of symptoms.
Stress echocardiography has a number of important advantages over other diagnostic tools in terms of the patient’s experience of care; it does not use ionizing radiation, which is especially important for young women and for those requiring repeated testing. Also, echocardiography is incredibly efficient, and most stress echocardiographic examinations are completed in less time than other cardiovascular imaging tests in a single visit. Finally, in terms of accessibility, most cardiologists’ offices and all hospitals have stress echocardiography capability and expertise. All of these features are important to the patient experience.
With regard to per capita cost, it is important to note that stress echocardiography is typically one of the least expensive among cardiac stress imaging tests, and it is superior to nonimaging stress tests. Finally, stress echocardiography can eliminate the need for two studies or test layering in some scenarios by providing information on ventricular and valve function, as well as inducible ischemia and myocardial viability. When image quality is suboptimal, the use of echocardiographic contrast adds considerable value to stress echocardiography.
Thus, when framed in the Triple Aim construct of population health dynamics, individual patient experience, and cost, it is easy to demonstrate the value of echocardiography for detection of CAD.
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