TABLE 1. Demographic Variables of the Respondents to the 51 of these studies (84%) revealed structural or func-
Survey tional heart disease.
Family Pediatrics Total In our center and in our regional clinics, the cost of
Practice a new cardiology evaluation including an ECG is less
Number 270 196 466 than $250, with the exception of those visits coded at
Male 239 121 360 the highest level of complexity. The cost of a com-
Female 31 75 106 plete pediatric echocardiogram in our area ranges
Average year training completed 1983 1982 1982 from $750 to $1270 (attributable to varying technical
charges), with an average cost of $965. Only 152 of
the respondents (33%) correctly estimated the cost of
echocardiogram or a cardiology referral for the following indica- the initial consultation to be less than $250. Two
tions: chest pain, syncope, an abnormal ECG, cardiomegaly on hundred sixty-four (57%) placed the cost between
CXR, and possible mitral valve prolapse. Demographic informa-
tion collected included gender, type of practice, and the year in $250 and $500, whereas the remainder estimated the
which residency training was completed. cost to be more than $500. As far as estimating echo-
To place survey responses in the context of our practice expe- cardiography costs, only 26 respondents (6%) cor-
rience, we reviewed our database for the 3-year period from rectly answered that they were greater than $750.
January 1995 to December 1997. In addition to our own laboratory,
we provide interpretations for pediatric echocardiograms per-
The majority (n 328, 70%) felt that the cost was less
formed at eight regional hospitals. Data collected on echocardio- than $500. Only 8 respondents (2%) estimated both
grams ordered by primary care physicians before cardiology re- echocardiography and consult costs in the correct
ferral included the patient’s age, study indication, and result. price range. In addition, 268 of the respondents (58%)
Echocardiograms ordered on newborns 1 month of age were
excluded because there were no on-site cardiology consultations
estimated that cardiology consultation was more or
available in all but one of the nurseries for which we offer echo- equally as costly as an echocardiogram.
cardiographic interpretation. It was then determined whether any When asked about the evaluation of a healthy
children with positive echocardiograms were subsequently seen 5-year-old child with a murmur, 44% of the respon-
in consultation. We also reviewed our own records for the most
recent calendar year to determine the frequency in which echo-
dents said that it was unlikely or very unlikely that
cardiograms were obtained on new outpatient referrals 1 month they would obtain a cardiology referral without or-
of age, and the results of those studies were noted. dering any tests first. Family practitioners were sig-
Data were analyzed using 2 tests, Cramer’s V, Kruskal-Wallis nificantly more likely than pediatricians (P .001) to
analysis of variances and Spearman’s r. Statistical significance was
defined as a P value .05.
include an echocardiogram as part of this initial eval-
uation, with 40% reporting that they were more than
RESULTS likely to do so compared with only 8% of pediatri-
During the 3-year period beginning in January cians. The physicians’ response to the questions
1995, we interpreted 209 echocardiograms in chil- about cost did not significantly correlate with their
dren 1 month of age ordered by primary care phy- likelihood of ordering an echocardiogram in this set-
sicians before cardiology consultation. A variety of ting. A majority of both pediatricians (63%) and fam-
indications were provided, but the majority (n 139) ily physicians (82%) felt that it was likely or very
of the studies were ordered for the evaluation of a likely that a cardiologist would obtain an echocar-
murmur. Of these, 117 (84%) were normal. Positive diogram as part of the office evaluation of this child.
findings in the other 22 studies included ventricular When asked if they would follow the child without
septal defect, atrial septal defect, bicuspid aortic referral if an echocardiogram they obtained revealed
valve, and mitral valve prolapse. Thirteen of the 22 a small ventricular septal defect, only 29% of the
children with an abnormal echocardiogram were re- pediatricians and 21% of the family physicians said
ferred to our center for cardiology evaluation. All they were likely to do so.
echocardiograms ordered by primary care physi- In the second scenario the physicians were given
cians for other common indications including the the additional information that the child’s insurance
evaluation of chest pain, syncope, possible mitral company would pay for tests done locally, but not
valve prolapse, or palpitations (n 41) were normal. for a local pediatric cardiology consultation. Pediat-
During 1997, our group evaluated 806 new outpa- ric cardiology consultation would be covered at a
tients [mt1 month of age. Echocardiograms were ob- center 90 minutes away. In this scenario, a higher
tained on 61 of these patients (7.6% of the total), and percentage of both pediatricians (28%) and family
TABLE 2. Kruskal Wallis Analysis of Variance of Differences Between Likelihood of Ordering an Echocardiogram and Practice Type
Diagnosis Pediatrics Family Practice P
Mean* SD Mean Mean* SD Mean
Chest pain 1.54 0.77 189 2.06 0.90 266 .001
Syncope 1.77 1.02 164 2.89 1.21 284 .001
Abnormal CXR 2.39 1.44 163 3.78 1.14 284 .001
Abnormal ECG 2.23 1.28 170 3.36 1.18 280 .001
R/O MVP 2.44 1.41 164 3.77 1.13 284 .001
Abbreviations: CXR, chest radiograph; ECG, electrocardiogram.
* Scale ranged from 1 (very unlikely) to 5 (very likely).
2 of 3 PRIMARY CARE PHYSICIANS’ USE OF SCREENING ECHOCARDIOGRAPHY
Downloaded from www.pediatrics.org by on July 22, 2010
practitioners (57%) replied that they would be likely The responses to our survey also indicate that the
to include an echocardiogram as part of their initial ready availability of specialist appointments may be
evaluation than in the first scenario. an important factor in the evaluation of heart disease
When considering the evaluation of the child with in children. If seeing a cardiologist imparts a time
chest pain, significantly more family physicians delay to diagnosis, or adds the expense and incon-
(63%) than pediatricians (34%, P .001) were likely venience of travel, physicians may be more likely to
to order an echocardiogram rather than wait 3 weeks use echocardiography. Parental pressure for a rapid
for a cardiology evaluation. Respondents were likely diagnosis may play an important role in this deci-
(r 0.43, P .001) to reconsider the decision to order sion.
the echocardiogram if the child could be seen by the Finally, family practitioners seem to be more in-
cardiologist in 2 days, although the association was clined than pediatricians to use echocardiography to
stronger for pediatricians (r 0.61, P .001) than evaluate children with suspected heart disease. The
family physicians (r 0.27, P .001). reasons behind this type of practice bias are not clear.
When asked about several problems without the Possibilities include fewer opportunities to evaluate
use of descriptive scenarios, family physicians were children with heart disease and to work with pedi-
significantly more likely to order echocardiograms to atric cardiologists during training, as well as differ-
evaluate syncope, an abnormal ECG, an abnormal
ent approaches to suspected heart disease in adults
CXR, and possible mitral valve prolapse than were
pediatricians (Table 2).
A limitation of this study was that only 57% of the
DISCUSSION physicians surveyed returned their surveys by mail.
Our survey results provide insight into the deci- Although this response rate is higher than for many
sion-making of primary care physicians as they eval- mailed surveys, it is possible that response bias may
uate possible congenital heart disease. In the model have been introduced.
proposed by Danford et al,1 the assumptions that Although costs of cardiology services and cardiol-
would make the use of echocardiography a more ogist practice patterns likely vary in different parts of
cost-effective strategy than cardiology referral would the country, certain aspects of our study should ap-
include inexpensive echocardiograms, expensive car- ply to all areas. Our survey suggests that improved
diology referrals, and the indiscriminate use of echo- physician education about their region’s cost of car-
cardiography by cardiologists. Although these as- diology services and cardiology practice patterns, as
sumptions are not true in our area, and presumably well as an improvement in the availability of special-
are not elsewhere, many primary care physicians in ist appointments, may help to reduce the number of
our area believe that they are. The majority of those expensive and often unnecessary echocardiographic
physicians responding to our survey significantly studies.
underestimated the cost of echocardiography, believ-
ing it to be cost-equivalent to cardiology consulta-
tion. Respondents also strongly believe that a pediatric REFERENCES
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http://www.pediatrics.org/cgi/content/full/103/4/e40 3 of 3
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Primary Care Physicians' Use of Screening Echocardiography
Andrew S. Bensky, Wesley Covitz and Robert H. DuRant
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