Value of Interactive Scanning for Improving the Outcome of New-Learners in Transcontinental Tele-Echocardiography (VISION-in-Tele-Echo) Study




Background


Point-of-care (POC) echocardiography may be helpful for mass triage, but such a strategy requires adequately trained sonographers at the remote site. The aim of this study was to test the feasibility of using a novel POC echocardiography training program for improving physicians’ imaging skills during preanesthetic cardiac evaluations performed in a community camp organized for treating cataract blindness.


Methods


Seventeen physicians were provided 6 hours of training in the use of POC echocardiography; nine were taught on site and eight were taught online through a transcontinental tele-echocardiography system. The trained physicians subsequently scanned elderly patients undergoing cataract surgery. The quality of images was graded, and agreement between local physicians’ interpretations and Web-based interpretations by worldwide experts was compared.


Results


A total of 968 studies were performed, with 660 used for validating physicians’ competence. Major cardiac abnormalities were seen in 136 patients (14.2%), with 32 (3.3%) deemed prohibitive to surgery in unmonitored settings. Although good-quality images were obtained more frequently by physicians trained on site rather than online ( P = .03), there were no differences between the two groups in agreement with expert interpretations. The majority of physicians (70.6%) expressed satisfaction with the training (average Likert-type scale score, 4.24 of 5), with no difference seen between the two groups. The training resulted in significant improvements in self-perceived competence in all components of POC echocardiography ( P < .001 for all).


Conclusions


This study establishes the feasibility of using short-duration, one-on-one, personalized transcontinental tele-echocardiography education for wider dissemination of echocardiographic skills to local physicians in remote communities, essential for optimizing global cardiovascular health.


Although physical assessment is an integral component of clinical evaluation, accurate clinical detection of structural heart diseases requires expertise and is difficult to standardize. Previous studies have demonstrated that the addition of an appropriate echocardiographic examination to the clinical assessment significantly increases diagnostic accuracy, reduces unwarranted diagnostic and treatment referrals, and facilitates the optimal utilization of health care resources. These observations have gained further impetus with recent advances in technology that have allowed the miniaturization of echocardiographic equipment, rendering echocardiography suitable for use as a point-of-care (POC) modality.


Echocardiography, however, requires expertise, for both image acquisition and interpretation, which limits its wider use in community settings. Our previous humanitarian project (the American Society of Echocardiography: Remote Echocardiography With Web-Based Assessments for Referrals at a Distance [ASE-REWARD] study) involved highly trained sonographers, and the data stored in the project revealed that Web-based integration of POC imaging with remote, expert interpretation of stored images could successfully extend high-level echocardiographic expertise to remote communities. However, the local availability of necessary expertise for image acquisition remained a challenge. Therefore, our second successive humanitarian mission had two objectives: (1) to test the feasibility of a Web-based training module for personalized remote ultrasound training in which physician trainees learn from remote educators by transmitting their handheld ultrasound images in real time during scanning sessions and (2) to compare the Web-based trained physicians with a group of physicians trained on site for overall proficiency in echocardiographic scanning and interpretation of studies performed in community settings. A cohort of elderly patients undergoing eye surgery in a mass community eye surgery camp was used to answer these research questions because of the known associations between cataracts and cardiovascular diseases. The quality of imaging and the overall accuracy of interpretations were validated by remote Web-based interpretation of stored images by worldwide echocardiography experts.


Methods


The project was conducted in two phases: initial training of physician sonographers (PhyS) and subsequent physician-driven echocardiographic evaluation during preanesthetic assessment in a community eye surgery camp ( Figure 1 ).




Figure 1


Project workflow.


Recruitment and Training of PhyS


Volunteer physicians without formal echocardiographic training but with varying previous experience in echocardiography were invited, through e-mail communications, to participate in the study. Seventeen PhyS (median age, 38.5 years; interquartile range, 36.3–43.5 years), who had obtained postgraduate qualification in various medical specialties (12 with diplomas in clinical cardiology and one each in internal medicine, psychiatry, anesthesia, maternal and child health, and anatomy) were ultimately recruited. The diploma in clinical cardiology is a 2-year training program available after medical school graduation, without any need to undergo prior residency in any medical specialty. The primary intent of this program is to train community physicians in providing appropriate clinical care to patients presenting with various cardiac illnesses in remote communities in India, where the burden of cardiovascular diseases has reached epidemic proportions. The median time interval since participants’ last medical qualification was 6 months (interquartile range, 6 months to 1.6 years).


Although none of these 17 PhyS had undertaken echocardiography fellowships or received formal structured training in echocardiography, they reported variable degrees of exposure to echocardiography previously. Six physicians reported previous experience of <6 months (with four having no experience at all), and five reported 6 months to 1 year of performing echocardiography without formal supervision. However, this experience did not represent regular time spent in an echocardiography laboratory performing scanning or interpreting studies on a regular basis but only “intermittently observing/performing” echocardiography when feasible during their regular clinical duties. Thus, their levels of expertise in echocardiography did not fulfill level 1 training criteria per the 2008 recommendations for training in adult cardiovascular medicine of Core Cardiology Training Symposium 3. The remaining six physicians had been performing echocardiography for durations that could meet Core Cardiology Training Symposium 3 level 1 criteria, but in the absence of formal, structured training in echocardiography, their overall competence in echocardiography remained nonuniform.


After recruitment in the project, the PhyS were provided 6 hours of focused training, at a tertiary care collaborating center in north India, in the performance of POC echocardiography by expert sonographer (ExpS) volunteers, who were American Society of Echocardiography (ASE) members with previous experience in teaching. Five ExpS traveled to India for onsite training of nine PhyS, whereas the remaining eight sonographers trained eight PhyS remotely through a Web-based tele-echocardiography system.


The training began with a 1-hour lecture that introduced the fundamentals of basic echocardiographic examination and oriented the participants to the specifically designed scanning protocol, consisting of 11 standard views, including color-flow Doppler images of all valves ( Appendix 2 ). This was followed by hands-on training using the pocket-size and handheld cardiac ultrasound units (Vscan and Vivid I and Vivid Q portable cardiac ultrasound systems, respectively; GE Medical Systems, Milwaukee, WI). The Vscan is a small, pocket-size device (135 × 73 × 28 mm), weighs <400 g, and has an 8.9-cm (diagonal) display with a resolution of 240 × 320 pixels. It uses a phased-array transducer (1.7–3.8 MHz) and displays grayscale images with a sector width of 75° and color Doppler with a fixed sector width of 30° and does not have the capabilities of spectral Doppler and M-mode imaging. The Vivid I and Vivid Q are laptop-based portable systems that allow more comprehensive examinations.


Remote Web-Based Training


Of the 17 PhyS, eight were trained remotely through a Web-based tele-echocardiography system. The live tele-echocardiography training was accomplished using Vivid I and Vivid Q systems connected to the internet via EchoBox (StatVideo LLC, Andover, MA) devices that allowed live streaming of echocardiographic images to designated Web portals. These images were accessed in real time by the ExpS in the United States, who simultaneously used a standard internet messaging application to communicate with the scanning physicians in India. Through these communication channels, the ExpS guided the scanning physicians through the whole process of image acquisition (machine settings, transducer position, etc) to image interpretation.


There was no difference in the level of expertise between the ExpS who were available on site and those who were involved in the remote training. In addition, both forms of training involved exposure to a similar spectrum of cardiac pathologies commonly encountered in clinical practice, such as various forms of valvular heart diseases, ischemic and nonischemic left ventricular (LV) systolic dysfunction, hypertensive heart disease, and so on. However, congenital heart disease (CHD) could not be represented, even though it was not purposely excluded.


Mass Echocardiographic Scanning in the Community Camp


The second phase of the study was conducted at a community eye surgery camp that is held annually in a spiritual organization in a rural location in north India. Although this was the location of our previous ASE-REWARD study as well, the two studies were conducted 11 months apart and included entirely different patient populations.


All patients who had been clinically examined by the surgical team and were deemed free of significant cardiac disease and fit to undergo surgery were included in the study and subjected to echocardiographic screening during the preanesthetic evaluation. Patients with known cardiovascular illnesses had already been excluded to avoid any unwarranted cardiac complications during the surgery performed in the camp.


Echocardiographic Examination, Image Transfer, and Interpretation


The scanning was performed by the PhyS under supervision of the ExpS, who ensured completion of the studies and also provided back-up support in the event of PhyS fatigue. The backup support was available to all PhyS, irrespective of mode of training and previous experience in echocardiography.


The studies were initially performed on Vscan, and whenever a major cardiac abnormality was identified that required better delineation, scanning was repeated on Vivid I and Vivid Q systems. All studies were digitally recorded in either a Motion Picture Experts Group layer 3 or Digital Imaging and Communications in Medicine format. Upon completion of each study, the PhyS generated a provisional echocardiographic report using a standardized template, which included information about chamber dimensions, valve morphology, color-flow Doppler, global and regional LV systolic function, and any apparent congenital cardiac malformations. Any other abnormality, if found, was also recorded. All studies were also uploaded to a cloud-based Web server (Studycast, Raleigh, NC), using commercially available software (CoreConnect; Core Sound Imaging, Raleigh, NC) that captured the study images from the ultrasound units and transmitted them to the image and workflow management component (CoreWeb; Core Sound Imaging). Worldwide interpretations of these uploaded studies were performed by 61 volunteer physicians with level 2 or 3 or equivalent training who had preregistered with the ASE. The reports were finalized on the Web-based system, using the same template used by the PhyS, with the goal of accomplishing this within 24 hours of initial scanning. The reports were subsequently downloaded and printed by the local coordinators, who distributed these reports to the patients. The remote readers were blinded to the interpretation made by the onsite readers.


For the purposes of analysis and interpretation, readers were requested to give only visual, qualitative assessments (mild, moderate, or severe) on specific pathologic issues: LV dilation, LV wall hypertrophy (concentric or asymmetric), reduction of LV function (visual ejection fraction), segmental wall motion abnormality (yes or no), right ventricular dilation, left atrial dilatation, aortic root dilatation, valve calcification, pericardial effusion, pleural effusion, and dilation with reduced inspiratory reactivity of inferior vena cava. LV ejection fraction was considered low if it was <55% by visual estimation and graded by ASE-recommended definitions for LV dysfunction as mild (45%–54%), moderate (30%–44%), and severe (<30%). The presence of valvular abnormalities (regurgitant or stenotic) and their grade (mild, moderate/severe) were also recorded. The severity of regurgitant lesions was based on two-dimensional findings (atrial or ventricular enlargement, hyperdynamic left ventricle) and qualitative color Doppler findings (width of vena contracta and jet area), whereas the severity of stenotic lesions was based on two-dimensional findings of valve opening and leaflet mobility, thickness, and calcification alongside chamber size changes (hypertrophy in aortic stenosis, atrial dilatation in mitral stenosis). An abnormality was considered major if any of the following was found: valvular regurgitation of moderate or greater severity, any valvular stenosis, all CHDs (except bicuspid aortic valves in the absence of any other associated significant abnormality), any LV systolic dysfunction or wall motion abnormality, and any other moderate or severe abnormality (e.g., moderate aortic root dilatation, moderate LV hypertrophy). All other echocardiographic abnormalities were deemed to be minor.


PhyS Survey about Their Experience


At the completion of the activity, the participating PhyS were administered a modified five-point, Likert-type scale questionnaire (1 = “completely dissatisfied/unconfident,” 3 = “neutral,” 5 = “completely satisfied/confident”) to collect information about their overall experience during the activity and the improvement, if any, in their self-perceived competence in difference components of using POC echocardiography ( Appendix 3 ).


Both the hospital and the state governmental authorities provided approval for this humanitarian and educational event. All patients consented to the preoperative workup (including echocardiography) and to undergo cataract surgery. All physicians and experts agreed to participate, including in the survey analysis. The hospital and local ethics committee provided approval for carrying out retrospective analysis of the stored information for research.


Data Analysis and Interpretation


All data were managed and analyzed using a Microsoft Excel 2007 spreadsheet (Microsoft Corporation, Redmond, WA). Continuous data are reported as the mean ± SD (or median and interquartile range, if not normally distributed), and categorical data are reported as numbers and percentages. Chi-square test was used to analyze differences in the categorical variables between the two training groups. Cohen’s κ was calculated as a measure of agreement between the onsite and remote expert interpretations. The responses to survey questions were analyzed using Mann-Whitney test or Wilcoxon signed rank test as appropriate. A P value <.05 was considered statistically significant.




Results


A total of 968 echocardiographic studies were performed during the entire activity. The mean age of the subjects was 57.9 ± 13.3 years, and 492 (50.8%) were men.


Overall Image Size, Data Flow, and Image Quality


On average, each study consisted of 19 ± 6 clips with an average size of 5.4 ± 2.7 MB. The median time delay from scanning to image upload was 8.35 hours (interquartile range, 4.51–21.24 hours) and from scanning to final interpretation was 10.65 hours (interquartile range, 3.92–24.47 hours).


Of the 968 scans, 861 (88.9%) were graded to have excellent, good, or fair image quality and another 46 (4.8%) as technically difficult but adequate. The remaining 61 (6.3%) had poor or limited image quality, but only 12 (1.2%) were nondiagnostic, precluding any meaningful interpretation. Importantly, there was no difference in the overall image quality across different skill levels (89.4%, 87.9%, and 85.3% of scans with fair to excellent image quality with PhyS with <6 months, 6 months to 1 year, and >1 year of previous experience in echocardiography; P = .41).


Echocardiographic Findings


Of the 956 (98.8%) scans that could be interpreted, 569 (59.5%) were found to be normal, 251 (26.3%) had minor abnormalities, and 136 (14.2%) had major abnormalities ( Table 1 , Figures 2 and 3 ).



Table 1

Major echocardiographic abnormalities in the study patients ( n = 136)


























































Echocardiographic abnormality Patients
Significant LV systolic dysfunction 64 (47.1%)
Regional 34 (25.0%)
Global 30 (22.1%)
Significant valvular heart disease 51 (37.5%)
Mixed valve disease and LV systolic dysfunction 13 (9.6%)
CHD 10 (7.4%)
Atrial septal defect 6 (4.4%)
Ventricular septal defect 4 (2.9%)
LV hypertrophy 10 (7.4%)
Concentric 8 (5.9%)
Asymmetric 2 (1.5%)
Other abnormalities 22 (16.2%)
Left atrial enlargement 13 (9.6%)
Right ventricular dilatation with or without dysfunction 4 (2.9%)
Aortic root dilatation 2 (1.5%)
Intra- or extracardiac mass 2 (1.5%)
Abnormal septal motion suggesting constrictive pericarditis 1 (0.7%)

Patients were assigned to particular diagnostic categories on the basis of the most dominant abnormalities found. When a patient had more than one severe abnormality, he or she was placed in all relevant categories.


Ten more patients had questionable evidence of CHD.


One patient had suspected aortic dissection.




Figure 2


Distribution of the overall minor and major echocardiographic findings in the study subjects. LA , Left atrial.



Figure 3


Illustrative examples of major cardiac lesions diagnosed by POC echocardiography in the camp. (A) Rheumatic heart disease with thickened mitral valve leaflets and doming of anterior mitral leaflet (arrow) resulting in significant mitral stenosis. (B) Markedly increased transmitral gradients consistent with severe mitral stenosis. (C) Another patient with rheumatic heart disease with posteriorly directed, eccentric severe mitral regurgitation. (D) Continuous-wave spectral Doppler across aortic valve showing significantly elevated transaortic gradients in a patient with severe aortic stenosis.


LV systolic dysfunction was the most common major cardiac abnormality, reported in 64 subjects (47.1% of those with major abnormalities), and was moderate to severe (LV ejection fraction < 45%) in 30 patients ( Video 1 ; available at www.onlinejase.com ). More than half of these patients ( n = 34 [53.1%]) had regional wall motion abnormalities, whereas the remaining had global LV systolic dysfunction.


Valvular heart disease was the second most common abnormality, with 51 patients (37.5% of those with major abnormalities) having significant valvular heart disease ( Tables 1 and 2 ) and another 156 patients (16.3%) having mild valvular heart disease ( Videos 2a, 2b, 3a, and 3b ; available at www.onlinejase.com ). Regurgitant lesions were more common than stenotic lesions, and the mitral valve was the most commonly involved valve. A wide array of other cardiac abnormalities, such as LV hypertrophy, left atrial dilatation, aortic root dilatation (with suspected aortic dissection in one patient; Video 4 ; available at www.onlinejase.com ), right heart enlargement, and so on, were also seen, but most often these abnormalities were only mild. In addition, 10 patients (1.0% of the total and 7.4% of those with major echocardiographic abnormalities) were found to have CHD (six with small atrial septal defects, four with small ventricular septal defects).



Table 2

Significant valvular heart disease in the study patients ( n = 51)








































Valvular heart disease Patients
Significant mitral valve disease 29 (56.9%)
Stenosis 7 (13.7%)
Regurgitation 16 (31.4%)
Both 6 (11.8%)
Significant aortic valve disease 24 (47.1%)
Stenosis 8 (15.7%)
Regurgitation 14 (27.5%)
Both 2 (3.9%)
Significant tricuspid valve disease 9 (17.6%)
Regurgitation 9 (17.6%)
Mixed valvular heart disease 12 (23.5%)

Patients were assigned to particular diagnostic categories on the basis of the most dominant abnormalities found. When a patient had more than one severe abnormality, he/she was placed in all relevant categories.



Significant Echocardiographic Abnormalities with Potential Surgical Implications


Of the patients with major echocardiographic abnormalities, 32 (3.3% of the entire study population) had pathologies (severe LV systolic dysfunction in 15 patients, significant valve lesions [severe valvular regurgitation and/or moderate to severe valvular stenosis] in 13, severe right heart enlargement in two, suspected aortic dissection in one, and hypertrophic obstructive cardiomyopathy in one) deemed prohibitive to cataract surgery in an unmonitored setting ( Figure 3 , Videos 1, 2a, 2b, 3a, 3b, and 4 ). As a result, their surgeries were rescheduled to be performed later in a hospital under cardiac monitoring.


Effect of Training Mode on Imaging Outcomes


A total of 192 scans were performed by ExpS during the training sessions. Of the remaining 776 scans, 116 scans had to be excluded because the copies of the provisional echocardiography reports retained for later analysis were not readable. The remaining 660 scans (346 by onsite-trained PhyS, 314 by remotely trained PhyS) were available for assessing the impact of training mode on imaging outcomes. A comparison of onsite and remote interpretations revealed that the PhyS could recognize major echocardiographic abnormalities with 58.7% sensitivity and 97.0% specificity (overall κ = 0.62, P < .001), though severity was underestimated by one grade in 11 studies (11.2%) and overestimated in another 11 (2.0%). Diagnostic accuracy was the best for valve lesions (sensitivity, 80.9%; specificity, 99.8%; κ = 0.88; P < .001) and relatively modest for LV systolic dysfunction (sensitivity, 58.0%; specificity, 98.3%; κ = 0.62; P < .001) ( Table 3 , Figure 4 ). Most of the observed differences between onsite and expert interpretations were related to localized LV wall motion abnormalities (hypokinesia or akinesia of one or two segments) and/or mild LV systolic dysfunction, CHDs (small atrial and ventricular septal defects), and chamber enlargements (left atrial, aortic root, or right ventricular dilatation or LV hypertrophy).



Table 3

Salient findings in the two groups by training methodology






































































































































Parameter Onsite-trained physicians ( n = 9) Remotely trained physicians ( n = 8) P
Total scans performed 346 314
Baseline echocardiographic experience of the scanning physicians .48
<6 mo 2 4
6 mo to 1 y 3 2
>1 y 4 2
Scans with fair to excellent image quality 312 (90.2%) 265 (84.4%) .03
Echocardiographic findings .30
Major abnormalities 43 (12.4%) 31 (9.9%)
Minor abnormalities 77 (22.3%) 84 (26.8%)
Diagnostic accuracy for major lesions
Overall diagnosis
Sensitivity (%) 59.1 58.1
Specificity (%) 96.8 97.3
κ 0.62 0.62 .32
LV systolic dysfunction
Sensitivity (%) 59.4 55.6
Specificity (%) 98.4 98.3
κ 0.65 0.58 .56
Valvular heart disease
Sensitivity (%) 81.5 80.0
Specificity (%) 99.7 100.0
κ 0.87 0.88 .65
Overall satisfaction with training quality
Average score ± SD 4.6 ± 0.5 3.9 ± 1.8 .87
Median 5.0 5.0

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Apr 21, 2018 | Posted by in CARDIOLOGY | Comments Off on Value of Interactive Scanning for Improving the Outcome of New-Learners in Transcontinental Tele-Echocardiography (VISION-in-Tele-Echo) Study

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