Echocardiography Underused in the United States Despite Performance Increase

Despite a recent increase in performance, echocardiography may still be underused in critical care.

Although rates of performance have increased in the United States, echocardiography may be underused during critical cardiovascular hospitalizations, according to data recently published in the Journal of the American College of Cardiology.

Researchers analyzed reports from the Nationwide Inpatient Sample (NIS) between 2001 and 2011 to investigate national trends, practice patterns, and patient outcomes associated with inpatient echocardiography.

“Recently, investigators have reported that echo use nearly doubled between 1999 and 2008, constituting approximately one-half of all cardiac imaging services among Medicare beneficiaries,” the authors noted. “Interestingly, however, our analysis of the largest publicly available all-payer inpatient database in the United States suggests that echo maybe underused for common and appropriate indications.”

After identifying the admission diagnoses most commonly associated with echocardiography use—acute myocardial infarction (AMI), cardiac dysrhythmia, acute cerebrovascular disease, congestive heart failure, coronary artery disease (CAD), valvular disease, nonspecific chest pain, and sepsis—the researchers performed a multivariate logistic regression within the patient populations for each diagnosis. They sought to assess whether echocardiography use was associated with all-cause inpatient mortality. Secondary analyses were performed to confirm trends in the NIS database.

The absolute volume of echocardiography steadily increased at an average annual rate of 3.41%, and absolute incidence increased by 3.04%.

In 2010, echocardiography use was associated with lower odds of inpatient mortality for AMI hospitalizations (adjusted odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.63- 0.86; P<.001). Echocardiography was also associated with lower cardiac dysrhythmias (OR: 0.72; 95% CI: 0.55-0.94; P=.02), acute cerebrovascular disease (OR: 0.36; 95% CI: 0.31-0.42; P<.001), congestive heart failure (OR: 0.82; 95% CI: 0.72-0.94; P=.005), and sepsis (OR: 0.77; 95% CI: 0.70-0.85; P<.001).

These 5 diagnoses accounted for 3.7 million (9%) of all hospital admissions in 2010. Use of echocardiography, however, was only used in 8% of these cases, suggesting that the procedure has been underused among patients who died during hospitalization.

CAD, valvular disease, and nonspecific chest pain samples did not demonstrate significance (CAD OR: 0.66; 95% CI: 0.40-1.08; P=.09; valvular disease OR: 0.71; 95% CI: 0.40-1.25; P=.24; nonspecific chest pain OR: 0.75; 95% CI: 0.18-3.15; P=.7).

The authors suggested that further studies should be conducted to identify the links between patient access to echocardiography and clinical outcomes among hospitalized patients in the United States.

“Because patient selection and appropriate echo use are key to cost efficiency, this study suggests that echo may be underused during critical cardiovascular hospitalizations, most notably in the treatment of AMI,” they concluded.


Papolos A, Narula J, Bavishi C, Chaudhry FA, Sengupta PP. US Hospital Use of Echocardiography. J Am Coll Cardiol. 2016; 67(5):502-511. doi: 10.1016/j.jacc.2015.10.090.