My dad was recently told he had a heart murmur by his internist. An echocardiogram (ultrasound of the heart) was ordered.
A heart murmur is basically any unusual sound that the doctor hears when he/she places a stethoscope on the anterior chest in the vicinity of the heart. Blood flows across various valves as it makes its way through the cardiac chambers. If the valves are functioning normally we usually can’t hear anything because the blood velocity is low and the flow is not disordered.
The majority of murmurs that are detected are due to either:
(1) narrowing (stenosis) of a valve that results in an acceleration of blood velocity.
(2) failure of a valve to close properly (insufficiency or regurgitation) and prevent back flow.
Cardiologists have developed an absolutely awesome tool for both visualizing the valves anatomical structure and movement, and precisely measuring the flow of blood through the heart.
The full name of this awesome tool is Doppler-echocardiography. The echocardiogram constructs a moving two-dimensional (more recently three-dimensional) “movie” from analyzing the time and intensity of sound waves reflected off the various valves, walls and structures within the heart.
The Doppler principle is utilized to precisely measure the location and velocity of blood flowing through the heart from high frequency sound waves reflected off red blood cells.
I call this test an echo or TTE (Transthoracic Echocardiogram)
The Importance of Being Expert in Echo Performance and Interpretation
I considered asking him to have the echocardiogram done at my hospital here in St. Louis. I’m the medical director of the laboratory and spend a lot of time making sure that we get high quality echocardiograms and that they are interpreted correctly.
When an echocardiogram is done elsewhere, I have no guarantees that it has been performed and/or interpreted properly.
One would hope that a TTE done in a doctor’s office in Tulsa, Oklahoma and one done in a hospital outpatient facility in St. Louis on the same patient would yield identical results on key findings, but this is often not the case.
On a regular basis, I see serious and highly significant errors made in the findings of TTEs performed elsewhere on patients that come to me for a second opinion or due to moving from another city.
Causes of Errors in Echos
The heart alone, among the body’s organs, is constantly moving. This means that standard ultrasound and x-ray techniques, which work great for static body parts, are useless. The techniques in a modern TTE that have evolved to fully evaluate all of the heart’s highly dynamic functions are complicated and require state-of-the art ultrasound equipment, as well as a sonographer who has been fully and expertly trained in using such equipment.
Such sonographers typically go through a two year program that is specific for cardiac ultrasound. To verify their knowledge and skills, they have a certification from either RDMS or CCT.
Will a competent, registered sonographer perform my dad’s exam? He and I have no way of knowing short of calling up the lab and asking very specific questions.
There is no government or insurance company mandate that a TTE be performed by a qualified, competent sonographer!
This, alone, is quite shocking, but it gets worse.
Who will read my dad’s TTE? Will it be read by a cardiologist trained like me who has gone through an additional year of cardiology training specifically in echocardiography, and who has reached what is termed Level III training?
Does that reading doctor have, like I do, verification of the acquisition and maintenance of the incredibly complicated knowledge base for echocardiography by taking and passing the National board of Echocardiography examinations?
Is he/she keeping up to date on new techniques and scientific findings in the field by attending regular CME sessions?
Does he/she regularly try to correlate the findings from the TTEs he/she reads with findings from other imaging techniques and surgical pathology?
Chances are the answers to all of the above questions will be no.
There is currently no country-wide government or insurance company mandate requiring the reader of a TTE to be competent to get reimbursed!
Thus, we have no guarantees that the TTE on my dad will be competently performed and interpreted.
This sad situation is the cause of the serious and significant errors in TTE results that I regularly encounter.
Dr. Kiran Sagar presented findings confirming this at the 2010 scientific meeting of the American Society of Echocardiography. According to news reports, she was fired shortly afterwards.
The study reported at the ASE meeting involved a review of 235 echocardiograms done at St. Luke’s hospital in Milwaukee, WI (not related at all to my St. Lukes hospital in Chesterfield, MO) from August 2007 to October 2008:
“Of the 35 physicians who performed clinical readings of the echocardiograms reviewed in the study, only three were Level 3 specialists within cardiology.
Sagar’s analysis revealed that 68 of the 235 imaging studies, or 29 percent, were misread.
In at least five of those cases, patients actually went into the operating room with a faulty diagnosis, although the problem was discovered before surgery was done.
In addition, 18 patients were subjected to more invasive echocardiography in which a probe was inserted down the throat and 19 underwent invasive coronary angiography. The misreadings also resulted in increased healthcare costs for the patients”
How Can You Be Sure Your Echo Is Competently Recorded And Interpreted.
I have no good answer to this question.
The only organization that provides any method for evaluation of individual echo labs is the Intersocietal Accreditation Commission. According to the IAC website “The purpose of the IAC Echocardiography accreditation program is “to ensure high quality patient care and to promote health care by providing a mechanism to encourage and recognize the provision of quality echocardiographic diagnostic evaluations by a process of accreditation.””
Echo labs that are accredited by IAC go through a process every three years that insures that they are following the IAC guidelines on acquisition and reporting. This means that the report from an IAC accredited echo lab will comment on all the structures of the heart that should be commented on and will report out basic, rudimentary measurements.
The IAC requires that the medical director of the echo lab have advanced training in echocardiography, but does not require the sonographers who perform the exams to be accredited.
There is no IAC requirement for significant evidence of competence or adequate training for the physicians who read echocardiograms. I quote from their documentation which states that a physician qualifies as a reader:
“if echocardiography training was completed prior to 1998 – three years of echocardiography practice experience and interpretation of at least 1200 echocardiogram/Doppler examinations…”
This type of physician reader does not have to document any significant training or competence, just that he/she has been reading echos for a while and has reached a certain volume.
My Dad’s Echo
We decided to let my dad get his echo done at the facility his primary care physician utilized. It was done at one of the largest hospitals in Tulsa, Oklahoma and I had him obtain both the report and the actual echo recordings for me to review.
The results were quite disappointing as several key elements of the exam were misinterpreted.
As I feared, my dad’s echo was botched.
What Americans Should Demand For Quality and Consistency in Echos
The payers in healthcare should mandate the following if an echo is to be reimbursed:
- It is performed in an IAC accredited echo laboratory
- It is performed by a registered sonographer
- It is interpreted by a cardiologist with advanced training and competence in echocardiography (how advanced and how that is measured or certified can be debated)
Until this kind of quality assurance is tied to reimbursement, it won’t happen voluntarily.