Trends in the use of cardiac imaging for patients with heart failure in Canada

Importance — Cardiac imaging is a component of the provision of medical care for heart failure that has experienced a broad expansion in the past decades. However, there is a paucity of studies examining the patterns of utilization of cardiac imaging modalities in real-world clinical practice.

Objectives — To investigate temporal trends in the utilization and costs of cardiac imaging for the investigation of heart failure and to examine the association between the institution of an accreditation program and the utilization of echocardiography.

Design, Setting, and Participants — Repeated cross-sectional study based on population-based administrative databases in Ontario, Canada of individuals with heart failure identified using a validated algorithm based on hospital admissions and ambulatory physician claims between April 1, 2002, and March 31, 2017.

Main Outcomes and Measures — Incidence and prevalence of heart failure. Age/sex-adjusted utilization rate and costs for cardiac imaging including rest and stress echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, computed tomography, magnetic resonance, and positron emission tomography.

Results — We identified 882,355 adults with prevalent heart failure (median age, 76 years; 50.1% female). The prevalence remained stable during the study affecting 2% of the adult population. There was a marked increase in the utilization rate of rest echocardiography from 386 tests (95% CI, 373-398) per 1000 heart failure patients in 2002 to 513 (95% CI, 501-526) per 1000 in 2011. Coinciding with the initiation of an accreditation program for echocardiography in 2012, there was an immediate reduction in the utilization rate (-59.5 tests per thousand, P <.001) which was followed by a plateau in subsequent years. At the same time, there was a reduction in the use of myocardial perfusion scintigraphy and invasive coronary angiography (10.8% and 11.2% relative decrease, respectively, from 2011 to 2016) and incorporation into practice of newer modalities after becoming publicly insured health services.

Conclusions and Relevance — Rest echocardiography remains the most used technique for imaging heart failure patients, exceeding the utilization and cost spent on other modalities. Stabilization in the utilization of traditional imaging modalities coincided temporally with the emergence of advanced techniques and province-wide quality improvement policy initiatives.