Trends in echocardiography utilization in the Veterans Administration Healthcare System

Abstract

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.

Temporal Trends in the Utilization of Echocardiography in Ontario, 2001 to 2009

“…Previous studies have shown minimal growth in the rate of repeat echocardiography but were limited to evaluating only the number of repeat studies within the same calendar year. (5,23) In our study, in which a repeat echocardiogram was defined as having occurred within 365 days of a prior outpatient procedure, repeat testing increased by an average of 10% per year.…”

“…The authors of that study hypothesized that Veterans Administration policy changes to increase the number of veterans eligible for services without an immediate increase in procedural capacity may have resulted in stabilization of echocardiography rates. (23) There were no such policy changes in Ontario during the study period we examined. In our study, physicians appeared to be increasingly reliant on echocardiography to clinically manage patients.…”

“…(23,31) Although procedure diagnoses have limitations in accuracy, they may be helpful for improving appropriate utilization. Firstly, clinician who are required to provide a diagnosis for refer may give additional consideration to the necessity for the procedure.…”

Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency

“…Importantly, we did not prevent any provider from ordering a study, even if it clearly would not have been indicated under the AUC or prompt scenarios. Alternatively, the increase in TTE ordering in more recent months may be due to the continued increase in the veteran population cared for at our institution, as previous analysis has shown much of the change in TTE ordering with the VA system over a several-year period was due to an increased number of patients rather than per-patient use 18. In fact, our small reduction in TTE ordering may have been larger if the veteran population for which DVAMC is responsible and the number of visits associated with that population had remained flat.…”

Medicare Services Provided by Cardiologists in the United States: 1999–2008

“…7 Our work confirms that growth of this modality remains steady and contrasts strikingly with the stability of echocardiography rates in the relatively fixed budget VA health care system: from 2000 -2007, the rate of echocardiography in the VA grew only 4%. 8 It is equally important to highlight that rates of some procedures, notably percutaneous coronary interventions (PCI), grew very modestly. From 1993-2001, PCI rates more than doubled in US Medicare beneficiaries 5 and nearly tripled in Ontario from 1992-2001.…”