Background There is growing concern over the impact of accelerating use of diagnostic imaging services on health care spending. Echocardiography is an important cardiovascular imaging procedure, but little is known about trends in its use or utilization. We examine trends in the utilization of echocardiography in a national health care system. Methods We used administrative data from the Veterans Healthcare Administration (VA) from 2000 to 2007 to identify patients receiving regular medical care (VA users) or echocardiograms at the VA. We then examined the number of echocardiograms performed each year within the VA and echocardiogram utilization (rates per 1,000 VA users). We examined changes in echocardiogram use and utilization over time and potential overuse of echocardiography. Results The number of echocardiograms increased from 92,269 in 2000 to 195,767 in 2007 (a 112.2% increase). Alternatively, echocardiogram utilization remained relatively stable, increasing from 68.8 per 1,000 VA users in 2000 to 71.5 per 1,000 VA users in 2007 because the number of VA users increased by 104.2% over the study period. The mean number of scans per year in echocardiogram recipients remained constant at 1.1/y, and the proportion of recipients receiving multiple scans remained constant at <10%. Conclusions Use of echocardiography in the VA increased dramatically between 2000 and 2007, but utilization rates increased only modestly. Our results suggest that, within the VA, growth in the use of echocardiography resulted from an increase in the number of patients receiving care from the VA on regular basis rather than the performance of a greater number of echocardiograms on a fixed patient population.

Purpose To compare echocardiography use among urban and rural veterans and whether differences could be accounted for by distance. Methods We used Veterans Administration (VA) administrative data from 1999 to 2007 to identify regular users of the VA Healthcare System (VA users) who did and did not receive echocardiography. Each veteran was categorized as residing in urban, rural or highly rural areas using RUCA codes. Poisson regression was used to compare echocardiography utilization rates among veterans residing in each area after adjusting for demographics, comorbidities, clustering of patients within VA networks and distance to the nearest VA medical center offering echocardiography. Findings Our study included 22.7 million veterans of whom 1.3 million (5.7%) received at least one echocardiogram. Of echocardiography recipients, 69.2% lived in urban, 22.0% in rural and 8.8% in highly rural areas. In analyses adjusting for patient demographics, comorbidities, and clustering, utilization of echocardiography was modestly lower for highly rural and rural veterans compared with urban veterans (42.0 vs 40.1 vs 43.1 echocardiograms per 1,000 VA users per year for highly rural, rural and urban, respectively; P < .001). After further adjusting for distance, echocardiography utilization was somewhat higher for veterans in highly rural and rural areas than it was for urban areas (44.9 vs 41.8 vs 40.8 for highly rural, rural and urban, respectively; P < .001). Conclusions Echocardiography utilization among rural and highly rural veterans was marginally lower than for urban veterans, but these differences can be accounted for by the greater distance of more rural veterans from facilities offering echocardiograms.

BACKGROUND: Left Ventricular Assist Devices (LVAD) have become the treatment of choice for many patients with advanced symptomatic heart failure who are not candidates for heart transplant (destination therapy) or who are waiting for a donor heart (bridge therapy). Little is however known about contemporary trends in LVAD volume, per-capita utilization and mortality especially among older patients. We examined trends related to LVAD implantation among the U.S. Medicare population. METHODS: Using Medicare inpatient data (MedPAR), we identified all fee-for-service beneficiaries age 65 and older who received LVADs between 2006 and 2010 using ICD-9 code 37.66. We examined the number of LVADs implanted each year and per-capita utilization (LVADs per 100,000 Medicare enrollees per-year) for every year during our study period. We also examined mortality rates during the index admission and within 90-days and 365-days from the index admission for each year. Trends over time were compared using Mantel-Haenszel test for trend. RESULTS: The number of LVADs implanted in fee-for-service Medicare beneficiaries age 65 and older increased from 145 in 2006 to 547 in 2010 (an increase of 277%). Among the 1,549 patients who received LVADs, mean age was 70.5 years (84% male, 85% white). Per-capita LVAD utilization increased by 245% from 1.1 per 100,000 patients in 2006, to 3.8 per 100,000 patients in 2010. In-hospital mortality decreased over the study period (40.7% in 2006 to 19.6% in 2010; P<0.0001) while 90-day mortality increased (82.8% in 2006 to 89.8% in 2010; P=0.02) as did one-year mortality (97.2% in 2006 to 100% in 2010; P=0.002). CONCLUSION: The utilization rate of LVADs in the Medicare population increased significantly between 2006 and 2010 and was accompanied by an increase in 90-day and one-year mortality despite a decrease in in-hospital mortality. These results and the trend towards increasing mortality warrant careful attention and consideration by physicians, patients, and policy makers.

BACKGROUND: Patients residing in rural areas may have reduced access to many medical services. This is a particular concern for highly regionalized delivery systems such as VA Healthcare System. We examine echocardiography (echo) utilization among veterans residing in urban and rural regions of the US. METHODS: We used VA administrative data to identify patients receiving care at the VA from 1999-2007. Patients were included during any year that they were engaged in care at the VA, defined by having at least 2 primary care visits during the year (“VA users”). For each year, we identified echos performed on VA users using CPT or ICD-9 codes. We classified each veteran as living in an urban, rural or highly rural region using the RUCA classification system. We compared demographics, comorbidity, and echo utilization rates per 1000 VA users among veterans living in each of the 3 regions using bivariate methods. We used logistic regression models to compare echo utilization for veterans residing in rural and highly rural areas with urban veterans serving as the reference while adjusting for patient demographics, comorbidity, and clustering of patients within 23 veteran integrated networks. RESULTS: Echo recipients residing in highly rural areas were older than residents in rural and urban areas (67.3 yrs vs. 66.7 yrs vs. 66.6 yrs), and more likely to be white, (76.5% vs. 73.6% vs. 59.4%). Unadjusted echo utilization was significantly higher for residents of urban areas compared to rural areas, but similar to highly rural areas (64.0 echos per 1000 per year for urban vs. 59.2 for rural vs. 63.7 for highly rural). In regression models however, we found that veterans living in rural and highly rural areas were slightly more likely to receive echos compared to veterans living in urban areas after adjusting for patient demographics and comorbidity (OR 1.03 95% CI 1.03-1.04 for rural and OR 1.13 95% CI 1.12-1.14 for isolated rural). CONCLUSION: We found no evidence that veterans residing in rural and highly rural regions of the U.S. had reduced utilization of echocardiography after adjusting for patient demographics and comorbidity. These findings suggest that the regionalization of the VA delivery system does not limit the performance of echocardiography for rural veterans.