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Effective Health Care Program

Data Points #20: Echocardiography Trends

Research Report

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This report is from AHRQ's Data Points Publication Series.

Overview

Echocardiography is a widely used procedure among the Medicare-enrolled population. Each year approximately 20% of enrollees in the fee-for-service (FFS) system receive at least one cardiac echocardiogram.

The percentage of enrollees who receive echocardiography services varies widely by geography. Use of echocardiography rises with age until age 85, where it plateaus.

Allowed health care charges for echocardiography decreased from 2007 through 2011 while the number of procedures rose slightly and the average number of procedures per beneficiary per year remained stable.

Heart disease is the leading cause of death for men and women in the United States. In 2010, heart disease caused more than one in four, or 27 percent, of deaths among individuals age 65 or older. Echocardiography is a noninvasive test that uses ultrasound waves to create pictures of the heart. An echocardiogram allows clinicians to see the structures of the heart and to see the motion of blood through the heart. It is often used by clinicians to assess, diagnose, and manage heart problems such as abnormal valves, atrial fibrillation, heart disease, heart murmurs, and other issues.

Use of echocardiography increased dramatically in the United States from the 1990s to early 2000s. This increase occurred at a higher rate than non-cardiac imaging services, and was greater than might be expected relative to the aging of the population. Between 2000 and 2010, the volume of imaging services increased by 81 percent within Medicare. Also by 2010, echocardiography services made up 11 percent of Medicare spending on imaging services, accounting for approximately $1.2 billion in spending. The growth in use of echocardiography may have slowed in the late 2000s, but it remains an often used procedure.

Efforts have been made to slow the increase in use of echocardiography through both payment and practice. The Deficit Reduction Act of 2005 reduced the Medicare payment for the technical com-ponent of echocardiography. In 2007, the Centers for Medicare & Medicaid Services (CMS) further reduced the amount paid for procedures beyond the index procedure on contiguous body parts during the same session. To address the possible overuse of echocardiography due to patterns of health care practice, a task force led by the American College of Cardiology Foundation (ACCF), American Society of Echocardiography (ASE), and specialty and subspecialty societies set out criteria for the appropriate use of echocardiography.

They concluded that "appropriate echocardiograms are those that are likely to contribute to improving patients' clinical outcomes, and importantly, inappropriate use of echocardiography may be potentially harmful to patients and generate unwarranted costs to the health care system." The criteria vary by previous service and clinical indication, but in general echocardiography testing is viewed as appropriate to assess conditions that have an indication of being cardiac in nature or to reassess diagnosed cardiac conditions when patients' symptoms have changed. Retesting to monitor a condition is considered inappropriate when patients' symptoms have not changed, there is no planned change in clinical management, and/or when fewer than one to three years have passed since the initial echocardiogram. One study estimates that the Deficit Reduction Act and the implementation of appropriateness criteria are two of multiple factors that have slowed the growth of echocardiography since 2005. However, the effect of these initiatives has not yet been quantified.

Understanding trends in the use of echocardiography remains complex. It appears that the growth may be due to primary care providers who are increasingly ordering echocardiograms using equipment in their own offices rather than an increase in use by specialty providers such as cardiologists. The presence of testing equipment for echocardiography in primary care offices has been hypothesized to be a possible driver of this increase in use by primary care physicians. This relationship is still unclear - in the case of stress echocardiography, the relationship between the office location of testing material and increased cost of care after testing is modest. However, evidence indicates that physicians of various specialties tend to increase their use of tests when they are able to self-refer.

Conclusion

Echocardiography is a widely used procedure among the Medicare-enrolled population. Each year approximately 20 percent of enrollees in the FFS system receive at least one cardiac echocardiogram. There is sizable geographic variation in use of echocardiography that deserves investigation. Recent changes in reimbursement policy appear to have reduced total allowed charges but have not led to shifts in the percentage of enrollees receiving services nor in the average number of echocardiography services per recipient.