ASE: More training needed to avoid echo discrepancies, high costs

Discrepancies during the interpretation of echocardiograms are prevalent and can have a negative impact on healthcare costs and may stem from differences in physician training, according to study results presented at the 21st annual American Society of Echocardiography (ASE) scientific sessions June 14 in San Diego.

“Inaccurate heart ultrasound readings can affect patients both physically and monetarily,” said study presenter Kiran B. Sagar, MD, a cardiologist from Medical College of Wisconsin in Milwaukee. “There are clear healthcare costs associated with inaccurate interpretations of these and similar health exams.”

M. Fuad Jan, MD, of Aurora Sinai/St. Luke’s Medication Center in Milwaukee, and colleagues evaluated the accuracy of echocardiogram interpretations and their association with physician training.

To do so, the researchers identified 14,248 transthoracic echocardiograms (TTE), 1,660 transesophageal echocardiograms (TEE) and 2,165 stress echocardiograms (SE) obtained between August 2007 and October 2008.

The researchers selected 235 studies—210 TTEs, 15 TEEs and 10 SEs—for review and reported on the major and minor discrepancies during interpretation between the original reader and the reviewer.

The studies were interpreted by 35 echocardiogram readers. Three had Level 3 training and National Echocardiographic Board Certification.

The results showed that after interpretations, 29 percent of reports had major discrepancies. And, according to the researchers, all major discrepancies occurred during evaluation by Level 2 echo readers compared to Level 3 readers.

During the study, the most common discrepancy pertained to the diagnosis of patent foramen ovale and atrial septal defect by TTE (18 patients). The researchers said that these discrepancies often led to further testing via TEE.

Other major discrepancies occurred during cardiac coronary angiography where there was a 40 percent discrepancy rate in the diagnosis of aortic valve disease. During TEE, mitral valve disease diagnosis discrepancies occurred in 37.5 percent of patients and 100 percent during the diagnosis of cardiac masses (six of six patients).

Major discrepancies of stress echocardiographs occurred in all five patients who underwent coronary angiography, .

“The exam is most cost effective when it is interpreted by a highly trained reader who can accurately diagnose the patient and avoid unnecessary subsequent exams,” said Sagar. “More cardiologists have been trained to perform invasive and interventional cardiac catheterization procedures than to accurately interpret heart ultrasound studies."

The authors said that physicians who interpret these exams must have a minimum of six months of training during a cardiology fellowship. To obtain Level 3 certification, physicians must experience 12 months of heart ultrasound training.

Additionally, the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) requires a minimum of five hours per year for training of heart ultrasound evaluation. However, Sagar said, “Our data show that the given hours a year as required by ICAEL are not enough.”

The authors concluded, “Physician training can significantly impact echo interpretation, with its attendant economic burden and patient safety issues.”