Saving Time and Money: Effectiveness of Outpatient Echocardiogram Utilization Review at an Academic Safety Net Hospital

Preeti Singhal^1,2, Reid Goodman^1,2*, Wesley Ghasem^2,3, Stephen Yau^2,3, Grace Liu^2,3, David Laughrun^2,3 and Wilson Kwan^2,3
*Correspondence: Reid Goodman, Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA, Tel: 5037509018, Email:

Keywords

Utilization review • Appropriate use criteria • Echocardiography • Cardiovascular imaging

List of Abbreviations

AUC: Appropriate Use Criteria; TTE: Transthoracic Echocardiography; TEE: Transesophageal Echocardiography; SE: Stress Echocardiography

Introduction

Echocardiography is the diagnostic cornerstone of contemporary cardiology; its widespread availability and minimal risk have resulted in increased utilization over the past two decades [1-4]. In response to concerns regarding overuse of echocardiography, the American College of Cardiology Foundation collaborated with other imaging societies to publish the 2007 Appropriate Use Criteria (AUC) to guide echocardiography imaging practices [5]. Subsequent investigations have shown that adherence to the AUC criteria paired with an AUC-based educational and feedback intervention has improved cardiac imaging ordering practices among physiciansin- training and attending physicians [1,6,7].

Reducing low-value echocardiography is of paramount importance to our large, urban medical center serving a largely indigent population. In response to the coronavirus disease 2019 (COVID-19) pandemic, the delivery of medical services at our institution, as with many others, was impacted and required significant changes in work-flow protocols to best allocate resources in a system already facing high volumes and a preexisting backlog. In such an environment, AUC to guide the use of echocardiography has significant cost-savings and resource allocation benefits [8]. Shortly after the onset of the pandemic, all non-urgent outpatient echocardiograms were postponed to mitigate the risk of exposure of patients, cardiac sonographers, and other staff to COVID-19 in the outpatient setting. Given the growing backlog of exams, a solution was urgently needed to triage orders and reduce exam volume.

We discuss a novel internal utilization review approach for outpatient echocardiography using our institution’s proprietary AUC (Figure 1) and perform a cost analysis on maintaining such a protocol.

Methods

Study environment

This study was conducted at Los Angeles County + University of Southern California (LAC+USC) Medical Center, a tertiary care academic medical institution in Los Angeles, California. 4074 outpatient echocardiogram orders, including transthoracic echocardiograms (TTE), transesophageal echocardiograms (TEE), and stress echocardiograms (SE) ordered between January 1, 2020 and April 1, 2021 were reviewed.

Data collection and echocardiography appropriateness classification

We designed and implemented a new work-flow protocol to guide the practice of echocardiography at our institution. Senior cardiology fellows were hired to prospectively review outpatient echocardiograms orders during the study period. The fellows underwent standardized training and carried out the review under the supervision of an attending faculty. The order date, specialty and clinical setting of the ordering provider, and clinical rationale for each echocardiogram order were determined via thorough review of the Electronic Medical Record (EMR). Echocardiographic studies were approved or canceled based on our institution’s modified AUC for echocardiography (Figure 1). Ordering providers received individualized messages in the EMR (linked to the patient’s chart) either approving or denying the echocardiogram order, along with a rationale for this classification. Clinical decision support was provided in cases requiring alternative diagnostic workup or not meeting modified AUC criteria. Time from echocardiogram order placement to study completion was also noted.

Outcome measures

The primary outcome measure was estimated total savings per year that resulted from instituting an outpatient echocardiogram internal utilization review. Secondary outcome measures included average wait time from order to completion of the echocardiographic study and rates of appropriate vs. inappropriate echocardiogram orders.

Results

Order characteristics

4075 orders placed between January 1, 2020 and April 1, 2021 was reviewed, including 3846 TTEs, 87 TEEs, and 141 SEs. Primary care accounted for the largest proportion of ordered exams (54.61%, n=2225), followed by cardiology (28.25%, n=1151). All other specialties accounted for the remainder of the studies ordered (17.14%) (Figure 2).

Appropriateness classification

Of reviewed orders, 32% (n=1304) were determined to be inappropriate and 68% (n=2771) were determined to be appropriate based on our institution’s modified AUC (Figure 1).

Wait time analysis

During the review process, echocardiogram orders that were identified as high priority, i.e. that would change management immediately, were scheduled to be done within one month. The average wait time between order to completion of the echocardiographic study, including those that were approved as per our institution’s modified AUC for echocardiography but not deemed high priority, decreased to 1.5 months from approximately six months by the end of the study period.

Cost analysis

Senior cardiology fellows from the sponsoring program were recruited to perform utilization review at a rate of $110 per hour under the direct supervision of attending cardiology faculty. The compensation for attending supervision was included in their annual salary, which remained static. An average of ten echocardiogram orders were reviewed by each reviewer per hour resulting in a marginal cost of $11 per order reviewed. The marginal cost of a technician performing an echocardiogram and an attending cardiologist reading the study at our institution is $81.40. Orders that were cancelled resulted in a savings of $70.40 (marginal cost of performing and interpreting a study minus the marginal cost of order review). Orders that were approved incurred the marginal cost of review ($11), resulting in a total cost of $92.40 per order.

Given that 68% of orders were approved and 32% were cancelled, averaged savings per order reviewed was $15.05 ([0.32 × $70.40] ‒ [0.68 × $11]).

During the study period, 4075 orders were reviewed, resulting in realized savings of $61,328.75 during the study period. Assuming that echocardiogram order volumes return to pre-pandemic levels (7152 outpatient echocardiograms were ordered on average each year from 2016-2019 at our institution) and a cancellation rate of 32%, approximately 2289 orders would be canceled resulting in projected annual savings of $107,637.60 (Table 1).

Discussion

We developed an internal utilization review protocol for outpatient echocardiograms performed at our large urban medical center in Los Angeles, California, an epicenter for COVID-19. Our intervention resulted in significant decreases in exam volume and improved appropriateness of studies performed. This may be attributable to the combination of ongoing provider education as part of the review process. While case-specific feedback is resource-intensive, we believe it leads to sustained results and can improve clinical decision-making beyond appropriateness of diagnostic testing. Reducing the number of inappropriate echocardiogram orders has mitigated echocardiogram wait times, overall costs and false positives requiring further potentially invasive testing.

Prior to initiation of our utilization review, the average wait from order to completion of an echocardiogram was approximately six months; by the end of the study period, the wait time had been reduced to approximately 1.5 months. The etiology for this change in wait time is suspected to be multifactorial. The majority of providers had fewer in-person visits during the peak of the pandemic and may have ordered fewer exams as a result. In addition, an additional echocardiogram technician was hired during the study period (increasing the total number of technicians from 6 to 7). Finally, providers may have ordered fewer inappropriate exams during the study period as a result of ongoing feedback and education.

Cost analysis for our internal utilization review for outpatient echocardiograms demonstrated projected annual savings of $107,637.60 per year, assuming pre-pandemic exam volumes. This amount is likely an underestimate, as equipment and administrative costs were not included in the marginal cost per echocardiogram. Hiring specialist physicians as independent reviewers of all outpatient echocardiogram orders at our institution significantly reduced low value studies and allowed for the prioritization of those studies that could change clinical management. Furthermore, we expect improved provider education to result in fewer ordered echocardiograms, which would continue to decrease costs; additional analysis is necessary to determine whether our utilization review has affected echocardiogram ordering patterns at our institution.

Limitations include the study period taking place during the COVID-19 pandemic, a time when individuals were more likely to change practice patterns to adapt to a harrowing situation and in the context of a research protocol. Furthermore, significantly fewer outpatient echocardiograms were noted to be ordered during the study period compared to an equivalent period in the pre-pandemic era, which may be due to multiple factors including a decrease in face-to-face patient visits and desire to minimize exposure to COVID-19 by physicians and patients.

In summary, our internal utilization review for outpatient echocardiograms relied on individual case-by case feedback and education by a trained specialist and resulted in an overall decrease in the number of inappropriate echocardiogram orders and waitlist times. While our method is more resource intensive when compared to other utilization review protocols or automated clinical decision support tools embedded within the EMR, we believe that it will lead to more effective and sustainable results even in a post-pandemic era. Via our educational component, we hope to create a better systems culture to sustain an increased percentage of appropriate echocardiogram orders over time.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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