Creating Opportunities to Guide Efficient and Cost-Effective Echocardiography in the Era of Value-Based Cardiac Imaging

Cardiovascular imaging procedures have consistently ranked among the most costly of Medicare services. Although reimbursement for an echocardiographic examination is decidedly lower than that for other cardiovascular imaging services, nearly 7 million cardiac ultrasound procedures were performed in 2012, and billing codes associated with its use have consistently ranked among the top 200 in Medicare expenditures. To this extent, even minor reductions in utilization costs for echocardiography could have a tremendous impact in lowering the overall economic burden of cardiovascular imaging services. Accordingly, opportunities remain for effective alternatives that could provide substantial cost savings to the health care system. Of recent note, the development of handheld cardiac ultrasound has prompted interest in assessing its potential to provide point-of-care imaging as a replacement for traditional transthoracic echocardiography (TTE), but at a decidedly reduced cost of services.

In this issue of the Journal of the American Society of Echocardiography , Kini et al . examine the potential for a limited imaging examination using expert focused cardiac ultrasound (eFCU) with a handheld scanner performed by level 2 echocardiographers as a means to reduce the costs associated with repeat or follow-up echocardiography. These results are relevant in that nearly one third of echocardiographic studies ordered are for repeat scanning. In this study, 105 hospitalized patients underwent both eFCU and TTE, predominantly for serial assessment of either pericardial effusion or left ventricular (LV) function. Concordance measures were relatively high between eFCU and TTE, with κ statistics of about 0.80 ( P < .001). Importantly, there was uniform categorization of markedly depressed versus preserved LV function for eFCU and transthoracic echocardiographic measures.

These results are intriguing in that not only were the measurements of the pericardium and LV function by eFCU congruent with those made by TTE, but also the use of eFCU was associated with substantial cost savings at this single center. The report by Kini et al . summed the labor and overhead costs for TTE and eFCU, noting a 56% cost savings. Guided by American Society of Echocardiography recommendations, it is essential to note that the relative value inputs for practice expenses for eFCU compared with TTE are markedly different, and it is inappropriate to apply the limited echocardiography code for eFCU. Given the prevalence of patients requiring serial echocardiography, it may be postulated that the use of focused imaging could exert sizable savings when extrapolated across the US health care system, affecting the economics of echocardiography-guided strategies and the lives of millions of Americans.

From an economic perspective, the study by Kini et al . was designed within a common theoretical framework of maximizing the health of a given population with constraints on resources that improve the efficiency of services provided. By evaluating multiple, equivalent options, the use of eFCU compared with TTE resulted in substantial cost savings, and by definition, this economic evaluation conceptually succeeded in the efficient allocation of limited resources within this echocardiography-guided strategy of follow-up testing. This type of assessment has been termed “technical efficiency,” whereby a given objective is met (e.g., serial comparison of LV function) at a lower cost. Of course, a repeat study would not be the final comparator of the lowest cost, but we assume that the indication for follow-up imaging is appropriate in this report on the basis of guideline-directed imaging. There are many examples within cardiovascular imaging in which the tenets of technical efficiency can be evaluated, and the present report is a textbook illustration of the necessary input cost valuations that are required for such an assessment. Detailed information on labor costs and other practice expenses can highlight important cost differences that may be positively leveraged in cost minimization equations.

Another critical component of this cost analysis is the ability of eFCU to evaluate pericardial effusions or LV function as reliably as TTE. It is only when the effectiveness component of quality-of-care measures is equivalent between two services that any cost savings can be meaningful. It is not uncommon for cost analyses to compare a higher with a lower cost procedure (or no testing at all) without consideration of the quality of services rendered to the patient. The foundation of patient-centered imaging is built on the ability to provide high-caliber imaging from which the translation to enhanced care for patients can then be inferred. Thus, the quality of care should be prioritized over cost savings. This approach was observed in Kini et al .’s study, in which the primary comparison was the accurate evaluation of either the pericardium or LV function followed by a secondary emphasis on cost savings.

Of course, in this series, eFCU was performed by expert echocardiographers, and the extent to which this influenced their results is unknown. It is unclear if these findings can be extended to community-based hospitals, clinics, or more remote populations, where the availability of trained cardiologists is limited. With that in mind, previous investigations have found improvements in clinical decision making with the use of handheld cardiac ultrasound by noncardiologists, which only heightens the growing excitement for “mainstream” use of these devices. Additional studies are certainly required to validate the accuracy of these devices in other clinical settings before any projection of reductions in spending can be applied to the greater national health care system. However, with technological advances and increasing sophistication of these handheld devices, it can be easily envisioned that guidelines for appropriate use could eventually include additional clinical indications. If and how the use of handheld devices directly translates to patient outcomes remains to be seen given the complexity surrounding many cardiac evaluations. If metrics used in cost analyses were capable of being expanded to include markers of morbidity and mortality, then the magnitude of potential downstream aggregate savings would assuredly be compounded.

The report by Kini et al . presents a novel approach for the use of eFCU, and their findings should prompt further evaluation of the potential for focused imaging that can track critical components of patient care in select clinical scenarios. Importantly, the focus of selective imaging should be on elements that could lead to a change in guideline-directed management. It is by applying this approach that echocardiography may improve outcomes vis-à-vis linking the examination to the timely initiation of risk-reducing intervention. This concept of intelligent cost containment, which forms the inherent model behind patient-centered imaging, becomes particularly important as more emphasis is being placed on improving the efficiency of high-quality care delivered to patients. eFCU appears to be a promising and potentially cost-effective strategy to foster this transition. The use of focused ultrasound examinations is but one method that may contribute to curtailing high health care costs for cardiovascular disease. There still exists a tremendous need for continued research and discovery to help develop additional viable strategies that may serve as benchmarks for cost-effective imaging-guided patient care.

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Apr 21, 2018 | Posted by in CARDIOLOGY | Comments Off on Creating Opportunities to Guide Efficient and Cost-Effective Echocardiography in the Era of Value-Based Cardiac Imaging

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