In the Journals

Echocardiography use for acute myocardial infarction tied to higher costs, longer hospital stays, no clinical benefits

Higher rates of echocardiography use for patients with acute myocardial infarction were not associated with better outcomes and were tied to longer hospital stays and higher costs, according to a study recent published in JAMA Internal Medicine.

“While echocardiography reports can inform clinical decisions and guide use of medications and procedures, only 32% of echocardiography examinations are associated with an active change in management and more than 20% of echocardiography reports are never subsequently acknowledged in the medical record,” Quinn R. Pack, MD, MSc, of the division of cardiovascular medicine, department of medicine, and the Institute for Healthcare Delivery and Population Science at the University of Massachusetts Medical School-Baystate, and colleagues wrote.

Researchers noted that clinical guidelines and performance measures recommend assessment of left ventricular ejection fraction, which is done primarily with echocardiography imaging, in patients with acute myocardial infarction (AMI), despite the low diagnostic yield of echocardiography.

To determine if use of echocardiography use affected outcomes in patients with AMI, researchers reviewed data from 397 hospitals, representing 15% to 20% of all inpatient hospitalizations in the United States from Jan 1, 2014, to Dec. 31, 2014. Researchers identified patients who were discharged with an AMI diagnosis during the study period and measured transthoracic echocardiography use for each admission. The primary outcomes were inpatient mortality, length of stay, total inpatient costs and 3-month readmission rate.

Risk-standardized echocardiography rates were calculated for each hospital and hospitals were grouped into quartiles from highest to lowest echocardiography use rates. Quartile echocardiography rates were calculated and compared to determine the difference across the groups.

Researchers identified 98,999 hospital admissions for AMI in the hospitals included in the study. Among those, 69,652 (70.4%) included at least one transthoracic echocardiogram with a median hospital risk-standardized rate of echocardiography of 72.5%.

After adjusting for patient characteristics, researchers found no significant difference in inpatient mortality (OR = 1.02; 95% CI, 0.88-1.19) or 3-month readmission rate (OR = 1.01; 95% CI, 0.93-1.1) in hospitals with the highest (83%) and lowest (54%) rates of echocardiography use.

Hospitals with the highest rate of echocardiography use had longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41) compared with hospitals with the lowest rates of echocardiography use. Researchers also found that hospitals with the highest rates of echocardiography use had higher mean costs ($3,164; 95% CI, 1,843-4,485) than those with the lowest rates.

“Our analyses suggest that, within the context of current clinical practice in the United States, more selective ordering of echocardiography has the potential to reduce costs without adversely affecting clinical outcomes, particularly at high-use hospitals,” Pack and colleagues wrote.

The researchers noted that their findings do not suggest that echocardiography does not have value in patients with AMI, but that there are clinical circumstances when it could be safely deferred. Pack and colleagues noted that further research is needed to determine clinical situations when an echocardiogram can be deferred. – by Erin Michael

Disclosures: Pack reported grants from the National Heart, Lung, and Blood Institute (NHLBI) during the conduct of the study. Please see study for all other authors’ relevant financial disclosures.

Higher rates of echocardiography use for patients with acute myocardial infarction were not associated with better outcomes and were tied to longer hospital stays and higher costs, according to a study recent published in JAMA Internal Medicine.

“While echocardiography reports can inform clinical decisions and guide use of medications and procedures, only 32% of echocardiography examinations are associated with an active change in management and more than 20% of echocardiography reports are never subsequently acknowledged in the medical record,” Quinn R. Pack, MD, MSc, of the division of cardiovascular medicine, department of medicine, and the Institute for Healthcare Delivery and Population Science at the University of Massachusetts Medical School-Baystate, and colleagues wrote.

Researchers noted that clinical guidelines and performance measures recommend assessment of left ventricular ejection fraction, which is done primarily with echocardiography imaging, in patients with acute myocardial infarction (AMI), despite the low diagnostic yield of echocardiography.

To determine if use of echocardiography use affected outcomes in patients with AMI, researchers reviewed data from 397 hospitals, representing 15% to 20% of all inpatient hospitalizations in the United States from Jan 1, 2014, to Dec. 31, 2014. Researchers identified patients who were discharged with an AMI diagnosis during the study period and measured transthoracic echocardiography use for each admission. The primary outcomes were inpatient mortality, length of stay, total inpatient costs and 3-month readmission rate.

Risk-standardized echocardiography rates were calculated for each hospital and hospitals were grouped into quartiles from highest to lowest echocardiography use rates. Quartile echocardiography rates were calculated and compared to determine the difference across the groups.

Researchers identified 98,999 hospital admissions for AMI in the hospitals included in the study. Among those, 69,652 (70.4%) included at least one transthoracic echocardiogram with a median hospital risk-standardized rate of echocardiography of 72.5%.

After adjusting for patient characteristics, researchers found no significant difference in inpatient mortality (OR = 1.02; 95% CI, 0.88-1.19) or 3-month readmission rate (OR = 1.01; 95% CI, 0.93-1.1) in hospitals with the highest (83%) and lowest (54%) rates of echocardiography use.

Hospitals with the highest rate of echocardiography use had longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41) compared with hospitals with the lowest rates of echocardiography use. Researchers also found that hospitals with the highest rates of echocardiography use had higher mean costs ($3,164; 95% CI, 1,843-4,485) than those with the lowest rates.

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“Our analyses suggest that, within the context of current clinical practice in the United States, more selective ordering of echocardiography has the potential to reduce costs without adversely affecting clinical outcomes, particularly at high-use hospitals,” Pack and colleagues wrote.

The researchers noted that their findings do not suggest that echocardiography does not have value in patients with AMI, but that there are clinical circumstances when it could be safely deferred. Pack and colleagues noted that further research is needed to determine clinical situations when an echocardiogram can be deferred. – by Erin Michael

Disclosures: Pack reported grants from the National Heart, Lung, and Blood Institute (NHLBI) during the conduct of the study. Please see study for all other authors’ relevant financial disclosures.