Background
The American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity aimed to study factors that could influence the clinical productivity of physicians and sonographers and assess longitudinal trends for the same. The first survey results indicated that productivity correlated with the total volume of echocardiograms.
Methods
Survey questions were designed to assess productivity for (1) physician full-time equivalent (FTE) allocated to echocardiography reading (echocardiograms per physician FTE per day), (2) sonographer FTE (echocardiograms per sonographer FTE per year), and (3) machine utilization (echocardiograms per machine per year). Questions were also posed to assess work flow and workforce.
Results
For fiscal year 2013 or academic year 2012–2013, the mean number of total echocardiograms—including outreach, transthoracic, fetal, and transesophageal echocardiograms—per physician FTE per day was 14.3 ± 5.9, the mean number of echocardiograms per sonographer FTE per year was 1,056 ± 441, and the mean number of echocardiograms per machine per year was 778 ± 303. Both physician and sonographer productivity was higher at high-volume surgical centers and with echocardiography slots scheduled concordantly with clinic visits. Having an advanced imaging fellow and outpatient sedation correlated negatively with clinical laboratory productivity. Machine utilization was greater in laboratories with higher sonographer and physician productivity and lower for machines obtained before 2009.
Conclusion
Measures of pediatric echocardiography laboratory staff productivity and machine utilization were shown to correlate positively with surgical volume, total echocardiography volumes, and concordant echocardiography scheduling; the same measures correlated negatively with having an advanced imaging fellow and outpatient sedation. There has been no significant change in staff productivity noted over two Committee on Pediatric Echocardiography Laboratory Productivity survey cycles, suggesting that hiring practices have matched laboratory volume increases.
Highlights
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Clinical productivity of physicians and sonographers can be used as a reference benchmark for staffing echocardiography laboratory.
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Surgical volume and workflow has a positive impact on physician productivity.
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Imaging fellow and outpatient sedation have a negative impact on physician productivity.
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Echo physician hiring practices appropriately matched echo volume increase over the two survey cycles.
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This survey allowed to assess need for imaging workforce over the next 3–4 years.
The American Society of Echocardiography (ASE) Committee on Pediatric Echocardiography Laboratory Productivity (C-PELP) was formed in 2008. The aim of this group was to study institutional factors influencing the clinical productivity of physicians and sonographers. In 2013, the first C-PELP survey results from 54 centers revealed that full-time equivalent (FTE) physicians interpreted an average of 15 studies per day, and sonographers performed an average of almost 1,300 studies per year. These productivity numbers were independent of surgical program size but correlated directly with total laboratory volume. The survey results provided useful benchmarks for the assessment of staffing needs in an academic echocardiography laboratory.
Identifying factors that improve work flow and thereby improve efficiency and productivity is crucial in the current economic environment. We hypothesized that evaluating longitudinal survey data from a large number of pediatric cardiology programs would enhance the understanding of echocardiography laboratory productivity that resulted from the first C-PELP survey. A second survey (C-PELP II) was hence initiated to assess these longitudinal trends as well as the projected growth of echocardiography laboratories and need for additional staff members and equipment.
Methods
The C-PELP II survey, containing 100 questions, was electronically distributed to the directors of 99 pediatric echocardiography laboratories in the United States and Canada ( Supplementary Appendix 1 ). All centers were identified through the ASE membership database, and the list included those with and those without pediatric cardiology fellowship programs. The survey collected information on the following:
- 1.
Laboratory characteristics: annual total number of echocardiograms, transthoracic echocardiograms (TTEs), transesophageal echocardiograms (TEEs), fetal echocardiograms, weekend echocardiograms, and surgical procedures (surgical volume was aggregated as <150, 150 to 249, 250 to 349, and >350), as well as the number of outreach sites if any and accreditation by the Intersocietal Accreditation Commission.
- 2.
Staffing: total number of physicians involved in covering the echocardiography laboratory, number of FTE physicians per day dedicated to the echocardiography laboratory, number of FTE physicians with advanced imaging training, budgeted versus actual number of sonographers, physician responsibilities for TTEs, TEEs, and fetal studies, physician responsibilities for performing and interpreting weekend echocardiograms, technical supervisor and director responsibilities, and sonographer responsibilities for TEEs and fetal studies.
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System or institutional practices: open versus closed laboratory (open defined as the capability to order echocardiograms without cardiology approval), integrated laboratory performing outpatient and inpatient TTEs as well as fetal studies, integrated outpatient sedation service, patient recovery and sedation practices, percentage outpatient sedated echocardiograms, automated ordering process through an electronic medical record system, predetermined laboratory patient schedule with allocated time slots, time allocated per echocardiogram (≤60 min vs no time allocation), echocardiograms performed in preassigned rooms and/or by preassigned sonographers, sonographer responsibility for entering study data and preliminary report, and personnel (including presence of advanced imaging fellows).
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Equipment: number of echocardiography machines; vendor diversity (one, two or three, or more than four vendors); machine age (acquired before 2005, between 2005 and 2008, or after 2009); equipment maintenance responsibilities; and data archiving, storage, and retrieval.
- 5.
Factors that influence investment decisions (new equipment or new personnel): projected increase in number of echocardiograms per year, demonstrated increase in volume, aging machine, or new technology.
Longitudinal Outcomes Assessment
The following three primary outcome measures were assessed for the purpose of both longitudinal assessment of clinical productivity and analysis of the second C-PELP survey:
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Physician productivity = number of echocardiograms/FTE physician/day.
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Sonographer productivity = number of echocardiograms/sonographer/year.
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Equipment productivity = number of echocardiograms/machine/year.
The potential need to hire new sonographers and physicians was assessed by collecting the following data: (1) number of sonographers and physicians hired in 2013, (2) possible positions in 2014, and (3) possible imaging positions in the next 3 years (2014–2017).
The survey was not designed to evaluate quality metrics, echocardiography complexity, or physician reimbursements (work relative value units).
Statistical Methods
Continuous variables were noted as averages and SDs and nonparametric variables as medians and ranges. A majority of the descriptive variables were dichotomous. Multiple correlations and analysis of variance were performed to assess for relationships, trends, and determinants of the three primary outcomes. Because a large number of variables was assessed, a P value < .01 was considered to indicate statistical significance.
Results
Of the 99 echocardiography laboratory directors contacted, 64 completed the survey. Nine programs submitted fiscal year 2013 data, and 55 submitted data for the academic year ending in June 2013. Sixteen programs performed <149 surgical procedures per year, six performed 150 to 249 per year, 14 performed 250—349 per year, and 29 performed ≥350 per year. Fifty-one programs (80%) had pediatric cardiology fellowship programs, and 20 (31%) had senior imaging fellowships. Designated technical directors were present in 58 (91%), with the following average distribution of responsibilities: 53% clinical, 44% administrative, and 3% research, suggesting that the typical technical director represented only a 0.5-FTE sonographer. The total number of echocardiograms performed is listed in Table 1 . The numbers of FTE physicians and sonographers allocated to coverage of all echocardiographic modalities are listed in Table 2 . Physician productivity, measured as the average number of studies interpreted by an FTE physician per day, was as follows: 14.3 ± 5.9 total echocardiograms (including outreach studies) per day, 12.5 ± 4.7 total echocardiograms (not including outreach studies) per day, and 17.7 ± 6.5 TTEs per day when the physician does not have TEE or fetal echocardiogram responsibilities ( Table 3 ). Physicians time spent on image acquisition averaged <10% and did not achieve statistical significance for the analysis. An average of 4.35 ± 4% of the TTEs were obtained under sedation. Sonographer productivity, measured as the average number of echocardiograms per FTE sonographer per year, was 1,056 ± 441 ( Table 4 ), and equipment productivity, measured as the average number of echocardiograms per machine per year, was 778 ± 303.
| Mean | SD | Median | Minimum | Maximum | |
|---|---|---|---|---|---|
| Total without outreach | 8,238 | 4,759 | 7,505 | 5,620 | 26,043 |
| TTEs | 7,543 | 4,777 | 6,590 | 5,271 | 24,550 |
| Fetal | 702 | 574 | 532 | 0.0 | 2,675 |
| TEEs | 326 | 244 | 294 | 0.0 | 1,400 |
| Total including outreach | 9,707 | 5,495 | 8,830 | 5,620 | 26,339 |
| Mean | SD | Median | Minimum | Maximum | |
|---|---|---|---|---|---|
| Physician (total) FTE/day | 2.7 | 1.1 | 2.5 | 1.0 | 6.0 |
| Physician TTE FTE/day | 1.8 | 1.0 | 1.5 | 0.5 | 8.0 |
| Physician fetal FTE/day | 0.6 | 0.3 | 0.5 | 0.1 | 1.6 |
| Physician TEE FTE/day | 0.5 | 0.3 | 0.5 | 0.0 | 1.0 |
| Sonographer FTE/day | 8.3 | 5.1 | 7.0 | 1.4 | 27.0 |
| Echocardiograms per physician FTE per day | Mean | SD | Median | Minimum | Maximum |
|---|---|---|---|---|---|
| Total | 12.5 | 4.7 | 12.4 | 1.4 | 23.5 |
| TTEs | 17.7 | 6.5 | 17.1 | 1.6 | 33.0 |
| Fetal | 5.2 | 4.3 | 4.2 | 0.0 | 12.4 |
| TEEs | 0.8 | 0.6 | 0.7 | 0.5 | 3.3 |
| Total with outreach | 14.3 | 5.9 | 14.3 | 3.4 | 29.0 |
| Mean | SD | Median | Minimum | Maximum | |
|---|---|---|---|---|---|
| Sonographer FTE/Day | 8.3 | 5.0 | 7.0 | 1.4 | 27.0 |
| Echocardiograms/FTE/year | 1,056 | 441 | 982 | 360 | 3,427 |
| Echocardiograms/FTE/Year with outreach | 1,221 | 500 | 1,244 | 318 | 3,642 |
| Echocardiograms/FTE/day | 5.0 | 2.2 | 5.0 | 1.7 | 16.0 |
| Echocardiograms/FTE/day with outreach | 5.8 | 2.4 | 6.0 | 2.0 | 17.0 |
| Echocardiograms/machine/year | 778 | 303 | 812 | 803 | 1,838 |
∗ Sonographer allocation and productivity measured by number of echocardiograms per FTE per year and per day. The echocardiograms performed per FTE per day are calculated assuming 210 working days per sonographer FTE.
Physician and Sonographer Productivity
Physician productivity was positively associated with surgical volume, total TTEs ( r = 0.50, P < .001), total TEEs ( r = 0.40, P < .001), total fetal studies ( r = 0.30, P < .01), number of FTE sonographers, number of machines, and echocardiograms per machine. In contrast, physician productivity was negatively associated with weekend echocardiograms, sedations, outreach, and having a senior imaging fellow ( Table 5 ). Physicians with other responsibilities while assigned to read echocardiograms also had a negative association with productivity ( P = .01).
| Primary outcome | Echocardiograms/sonographer FTE/year | Echocardiograms/physician FTE/day | Echocardiograms/machine/year | |||
|---|---|---|---|---|---|---|
| Variable | Pearson’s correlation | P | Pearson’s correlation | P | Pearson’s correlation | P |
| Echocardiograms/physician FTE/day | 0.14 | .27 | 0.42 | .00001 ∗ | ||
| Echocardiograms/sonographer FTE/year | 1 | 0.14 | .26 | 0.62 | .00001 ∗ | |
| Echocardiograms/machine/year | 0.62 | .00001 ∗ | 0.50 | .00001 ∗ | 1 | |
| Weekend echocardiograms | 0.90 | .0008 ∗ | 0.30 | .00006 † | 0.18 | .16 |
| Surgical program size | 0.40 | .70 | 0.60 | .00001 ∗ | 0.36 | .03 |
| Total sonographer FTE | −0.30 | .05 | 0.40 | .002 ∗ | −0.02 | .90 |
| Total echocardiography machines | −0.16 | .20 | 0.40 | .001 ∗ | −0.26 | .05 |
| Advanced imaging fellowship | .80 | .02 | .60 | |||
| Weekend and weeknight sonographer coverage | .0005 ∗ | .35 | .60 | |||
| Scheduled time slots for studies | .07 | .008 ∗ | .80 | |||
| Outpatient sedation | .003 † | .04 † | .50 | |||
| Echocardiography schedule coordinated with outpatient clinic schedule | .30 | .30 | .03 | |||
| Preliminary data and reports entered by sonographer | .10 | .60 | .86 | |||
| Physicians with additional responsibilities | .02 † | .01 † | .05 † | |||
∗ Statistically significant ( P < .01).
Sonographer productivity was positively associated with outreach, weeknight and weekend echocardiography responsibility, and machine productivity. Outpatient sedated echocardiograms integrated into outpatient laboratory work flow had a negative impact ( Table 5 ).
Sonographer responsibilities of performing numeric data entry, (72%), calculations (94%), and preliminary echocardiography reports (32%) did not affect sonographer productivity significantly, but creating preliminary reports trended toward a negative association ( P = .04).
Equipment Productivity
Equipment productivity was affected mainly by sonographer and physician productivity ( Table 5 ). Using a machine acquired before 2009 had a negative impact ( r = −0.30) on equipment productivity, but vendor diversity did not. Thirty-seven laboratories (59%) used only a single vendor, 24 (38%) used two or three vendors, and only two laboratories used five vendors. Machine age was analyzed on the basis of whether a machine was acquired before or in 2009 and thereafter. All machines were purchased after 2008 for 10 laboratories, 75% to 92% were purchased after 2008 for 14 laboratories, and 50% to 75% were purchased after 2008 for 18 laboratories; all machines were purchased before 2009 for four laboratories, and >50% were purchased before 2009 for 16 laboratories. Neither vendor diversity nor machine age influenced physician and sonographer productivity. Additionally, neither vendor diversity nor machine age correlated with surgical volume.
Institutional and Laboratory Characteristics
Sixty laboratories (92%) had outpatient sedation services, and 46 (60%) had integrated inpatient services (one laboratory was responsible for both inpatient and outpatient studies). Integrated fetal services were present in 39 laboratories (62%). Physicians reviewed images before patient discharge in 37 laboratories (58%). Scheduled outpatient echocardiography slots were synchronized with clinic appointments in 21 (32%), a hybrid model involving both coordinated echocardiography and clinic scheduling and add-ons was present in 41 (63%), and three laboratories (5%) had no predefined schedules. Intersocietal Accreditation Commission accreditation was obtained for TTEs in 94%, for TEEs in 72%, and for fetal studies in 83%. Several laboratory characteristics correlated with surgical size.
As expected, larger surgical programs were more likely to perform large numbers of TTEs, TEEs, and outreach studies ( Table 6 ). Surgical centers with <149 surgical procedures per year had smaller fetal echocardiography volumes compared with the larger centers ( Table 6 ). Centers with surgical volume ≤349 per year were more likely to have integrated services (no separate fetal or sedation service) as well as physicians with combined service responsibilities. Physician productivity and equipment productivity were significantly lower at centers with surgical volume <149 per year ( Table 6 ). Centers with >250 surgical procedures per year were also more likely to have physicians with advanced imaging training compared with centers with <249 procedures per year (75% vs 54% of reading physicians, respectively).
