Study Examines Use of Transthoracic Echocardiography

A study of the use of transthoracic echocardiography (TTE) at an academic medical center suggests that although 9 in 10 of the procedures were appropriate under 2011 appropriate use criteria, less than 1 in 3 of the TTEs resulted in an active change in care, according to a report of the research by Susan Matulevicius, M.D., and colleagues at the University of Texas Southwestern Medical Center, Dallas.1

The researchers, who studied 535 patients undergoing TTE, found that, overall, 31.8 percent of TTEs resulted in an active change in care; 46.9 percent resulted in a continuation of current care; and 21.3 percent prompted no change in care, according to the results.

“The low rate of active change in care (31.8 percent) among TTEs mostly classified as appropriate (91.8 percent) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care,” the study concludes.

In a related commentary2,  John P.A. Ioannidis, M.D., D.Sc., of Stanford University, California, writes: “Transthoracic echocardiography is the most popular cardiac imaging study; approximately 700 TTE studies are performed annually per 1,000 Medicare beneficiaries. Given its popularity, cost can easily escalate unless some restriction is set on which TTEs are deemed appropriate to perform.”

“The study by Matulevicius et al demonstrates that the concepts of appropriateness and usefulness may diverge considerably. Transthoracic echocardiograms cost more than $1 billion per year to Medicare alone, and many TTE procedures performed by the book may still not lead to improved outcomes,” he writes.

In a related commentary3, William Armstrong, M.D., and Kim A. Eagle, M.D., of the University of Michigan Medical Center, Ann Arbor, write: “Matulevicius and colleagues compare the clinical impact of transthoracic echocardiograms (TTEs) with the classification of the echocardiogram by the 2011 appropriate use criteria (AUC). They find that, although 91.8 percent of TTEs were appropriate, only 1 in 3 resulted in an active change in clinical management; approximately 1 in 2, in continuation of current care; and approximately 20 percent, in no change in current care.”

“The degree to which these outcomes are exclusively shortcomings of the AUC is debatable but raises concerns that further modifications – and probably physician education – are necessary to achieve a more efficient use of echocardiography and conserve resources,” they continue.

“The AUC are under a constant state of iteration and investigation; clearly the 2011 revision addresses many of the shortcomings of the earlier versions. Certainly, the AUC are not without remaining flaws and ideally should result in a categorization scheme that can be demonstrated to have a consistent, but not necessarily invariable, effect on medical decision making. This retrospective study points the way for further prospective studies looking at the impact of echocardiography and how it affects physician decision making,” they conclude.


1. JAMA Intern Med. Published online July 22, 2013. doi:10.1001/jamainternmed.2013.8972.

2. JAMA Intern Med. Published online July 22, 2013. doi:10.1001/jamainternmed.2013.6582

3. JAMA Intern Med. Published online July 22, 2013. doi:10.1001/jamainternmed.2013.7273.