Rates of echocardiograms increasing steadily in Ontario

A new study from the Institute for Clinical Evaluative Sciences (ICES) and Sunnybrook’s Schulich Heart Centre suggests that improvements are needed in the way echocardiograms are administered and tracked in Ontario. Echocardiograms — also known as echos — are ultrasounds of the heart that are performed by physicians to aid in the diagnosis of patients with different types of heart disease.

The study found a 5.5 per cent annual rise in new echocardiograms, and a 10.6 per cent annual increase in repeat echocardiograms in Ontario between 2001 and 2009. This translates into a 53 percent increase during the study period. While 25 per cent of all echos were performed by non-cardiologists, the majority of echocardiograms were performed by cardiac specialists throughout the study period, and these cardiologists performed 87 per cent more echocardiograms in 2009 than in 2001. Meanwhile, the burden of cardiac disease on the Ontario healthcare system has been relatively stable.

Dr. Jack Tu, senior author on the study, said, “The utilization and rising cost of cardiovascular imaging procedures have been attracting the attention of payers and providers in Canada and the U.S., so it is a significant finding that the rate of echocardiography grew so significantly during the period of this study. In contrast, rates of certain types of heart disease actually fell during this period.”

This population-based, repeated cross-sectional study of 4,234,166 outpatient echocardiograms found that the significant increases in echocardiography utilization were particularly related to repeat procedures. In fact, repeat echos accounted for 25.3 per cent of all procedures in 2009, compared to 18.5 per cent in 2002. “About half of these repeat echos were done by the same physician and about half were done by another physician,” said Tu, who is also the program lead in cardiovascular and diagnostic imaging research at ICES and a staff cardiologist at Sunnybrook’s Schulich Heart Centre.

“All of this suggests that many of these repeat tests may be related to inefficiencies in the current healthcare system,” said Tu. The study also found that the cardiac diagnosis was missing from the physician billing claim for echos in 73 per cent of patients. “Without a diagnosis code, we could not track indications for procedure. Requiring these codes may improve clinical decision-making regarding diagnostic procedures,” Tu said.

The rapidly increasing rates of echocardiography in Ontario and high rates of repeat testing raise concerns about whether all of the use of echocardiography is being done for clinically appropriate reasons. It is currently not possible to determine the ‘appropriateness’ of the reasons behind this rise because information on the clinical indications for echocardiography is not collected in Ontario. In addition, Ontario also does not require formal training of echocardiographers or certification of laboratories performing echocardiography, unlike some other provinces in Canada. “We recommend that given concerns about the appropriateness and costs of rapidly increasing rates of echocardiography, Ontario should start to collect data on the indications for echocardiography and that mandatory criterion for training of echocardiographers and certification of laboratories be introduced to help improve the clinical utility of these tests,” said Tu.

Ontario spent about $130 million on echocardiograms in 2009.

The study “Temporal trends in the utilization of echocardiography in Ontario, 2001 to 2009” was published today in the journal JACC: Cardiovascular Imaging.

Author block: Saul Blecker, R. Sacha Bhatia, John J. You, Douglas S. Lee, David A. Alter, Julie T. Wang, Hannah J. Wong, Jack V. Tu

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

Sunnybrook Health Sciences Centre is inventing the future of healthcare for the 1.2 million patients the hospital cares for each year through the dedication of its more than 10,000 staff and volunteers. An internationally recognized leader in research and education and a full affiliation with the University of Toronto distinguishes Sunnybrook as one of Canada’s premier academic health sciences centres. Sunnybrook specializes in caring for high-risk pregnancies, critically-ill newborns and adults, offering specialized rehabilitation and treating and preventing cancer, cardiovascular disease, neurological and psychiatric disorders, orthopaedic and arthritic conditions and traumatic injuries. The hospital also has a unique and national leading program for the care of Canada’s war veterans. For more information about how Sunnybrook is inventing the future of healthcare, visit us online at www.sunnybrook.ca

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