Echo Overuse in Heart Failure Stabilizes in the Wake of Ontario Appropriateness Efforts

The use of rest echocardiography in the diagnosis and management of patients with heart failure increased significantly over a recent 10-year period, growing at a rate that was disproportionate to the occurrence of heart failure in the population, according to a new analysis examining the utilization of cardiac imaging in Ontario, Canada.

While the incidence of heart failure decreased significantly and the prevalence remained relatively stable, investigators report that the adjusted use of rest echocardiography increased by nearly 40% between 2002 and 2011, then plateaued; this finding appears to be tied to the start of an accreditation program intended to discourage inappropriate imaging procedures.

“With cardiac imaging and important healthcare resources, there were concerns about overuse and I think people are trying hard—health professionals, the Ministry of Health, politicians, and so on—and I think the efforts are changing the patterns in terms of how doctors are ordering exams,” said lead investigator Juarez Braga, MD (ICES, Toronto, Canada). “I think it’s good news, at least the use of [echocardiography] is not increasing that much any longer. We’re all trying hard to avoid overuse.”

Several imaging modalities, among them traditional tests like echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, as well as more advanced technologies such as coronary CT angiography, cardiac MRI, and positron emission tomography (PET), are used in the diagnosis and management of patients with heart failure. While patients with heart failure are living longer and will require more imaging tests over time, there had been some concerns about the overuse of certain imaging technologies, said Braga.

The Cardiac Care Network of Ontario, now known as CorHealth Ontario, created the accreditation program for echocardiography readers and laboratories and established standards for the provision of echocardiography in the province. The program is designed to ensure that all echo studies meet the appropriate use criteria set out by the American College of Cardiology, American Heart Association, and American Society of Echocardiography.

We’re all trying hard to avoid overuse. Juarez Braga

For the current study, which was published August 8, 2019, in JAMA Network Open, investigators tracked the use and costs of cardiac imaging for heart failure patients treated in Ontario, Canada, to determine if instituted policy changes, as well as the publication of appropriate use criteria, were having an effect on resource and cost containment.

Achieving the Goal

In this population-based study, the researchers identified 882,355 individuals (median age 76 years; 50.1% female) with heart failure between 2002 and 2016. During this time, the age- and sex-standardized prevalence of heart failure remained stable, ranging from 2.41% in 2002 to 1.98% in 2016. The annual number of incident heart failure cases ranged from 38,560 individuals in 2002 to 39,754 in 2016, with the age- and sex-standardized incidence rate declining significantly from 380 cases per 100,000 people in 2002 to 256 cases per 100,000 in 2016.

Despite the stable prevalence and declining incidence of heart failure, the age- and sex-standardized utilization rate of rest echocardiography increased 25% during the study period, from 386 tests per 1,000 heart failure patients in 2002 to 513 tests per 1,000 patients in 2016 (P = 0.001). Use of rest echo peaked in 2011, decreased in 2012, and then plateaued for the rest of the study period. After the start of a provincial echocardiography accreditation program in 2012, there was a decrease of 59.5 tests per 1,000 heart failure patients. 

“We know that echo is important and [should] be used rationally,” said Braga. The accreditation program, he added, appears to be achieving its goal. He also noted other efforts likely contributed to the decline in the use of rest echocardiography, including the 2013 publication from several societies, including the American College of Cardiology, on the appropriate use of cardiovascular imaging in heart failure and the “Choosing Wisely” program from the American Society of Echocardiography. “We can’t rule out the impact of each of these measures,” said Braga.

Costs Dominated by Echocardiography

The use of stress echocardiography increased during the study between 2002 and 2016, but its use represented less than 5% of all echocardiograms performed. There was a decline in the use of myocardial perfusion scintigraphy after 2012 and a relative stable utilization of invasive coronary angiography. Use of coronary CT angiography was unchanged from 2011 to 2016, while cardiac MRI use increased from three tests per 1,000 people in 2002 to 30 tests per 1,000 in 2016. Use of cardiac PET was limited and unchanged during the study period.

This is a demonstration of a proof-of-principle: we can control the use of cardiac imaging. Douglas Lee

Overall, annual expenditures for cardiac imaging increased from $24.8 million in 2002 to $49.6 million in 2016. Braga noted that the investigation of heart failure is still dominated by traditional imaging tests such as rest echocardiography, nuclear perfusion scintigraphy, and invasive coronary angiography.

“The results for echo were impressive, in my opinion,” said Braga. “We found that echo was responsible for more than 50% of all costs [in 2016] related to cardiac imaging in this population. We knew beforehand that echo was important—it is the main modality for heart failure—but we were surprised by the number.” In contrast, advanced modalities such as CT angiography, MRI, stress echocardiography, and PET accounted for just 5% of all expenses from cardiac imaging in 2016, he noted.

Senior investigator Douglas Lee, MD (ICES/University Health Network, Toronto, Canada), noted the study shows that physicians can contain costs and prevent overuse when necessary.

“Cardiac imaging is an important part of heart failure management, and I think an important take-away is that this is a demonstration of a proof-of-principle: we can control the use of cardiac imaging,” he told TCTMD. “We’re able to do these tests and control their use through measures such as accreditation programs, appropriate use criteria, and physician leaders who are helping lead the charge around this. This is a demonstration that something can be done about the potential for overuse with some cardiac imaging tests.”   

Vinay Kini, MD (University of Colorado Anschutz Medical Center, Aurora, CO), who wrote an editorial accompanying the study, said the Ontario findings “mirror the rapid increase and decrease in the rate of growth of diagnostic cardiovascular imaging in the United States.”

Given the observational nature of the study, though, it does not provide information on the usefulness of completed imaging tests, nor does it establish causality or a connection to the instituted policy changes. Still, Kini praised the researchers, stating that there is a role for observational studies assessing imaging use in clinical practice. But he also stressed that future studies are needed to “gain a better understanding of the causal factors affecting cardiac imaging and the effect of changes in use on imaging quality.”