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Publication Briefs

Echocardiography Testing Can Be Redesigned to Answer Focused Diagnostic Questions While Reducing Costs

A focus of high-value healthcare has been eliminating unnecessary medical tests. Echocardiography accounts for more than $900 million in annual Medicare spending, with studies suggesting that at least 5% to 20% of testing may be inappropriate. One way to reduce costs – for simple indications – includes a brief echocardiogram with minimal views and measurements that might answer diagnostic questions. With this aim, in 2006 the VA Palo Alto Health Care System (PAVA) added an alternative to the standard transthoracic echocardiogram (TTE; cost= $240) that evaluated only the left ventricle (LV-TTE; cost = $60). Evaluation of left ventricular ejection fraction is one of the most common indications for a TTE. Investigators in this study evaluated the use of this new option and its association with the overall use of TTE. Using VA data, investigators assessed the number of annual TTEs and outpatient visits for PAVA – and for 118 VA hospitals (control group) between January 2005 and December 2015. They then evaluated the association between the introduction of LV-TEEs at the PAVA and TTE volume, controlling for hospital fixed effects, number of outpatient visits, and the patient's age.


  • The volume of TTEs, number of outpatient visits, and mean age of patients were similar at the PAVA and the 118 control hospitals in 2005. But between 2011 and 2015, limited TTEs – as a percentage of total TTEs – increased to 19.5% at the PAVA (from a baseline of 0.8% in 2005) compared to 2% at the control hospitals.
  • With multivariable regression, the introduction of LV-TTEs was associated with 349.5 more limited TTEs, but no significant change in total TTEs.


  • Study results suggest that LV-TTE was substituted in place of a full TTE and that echocardiography testing can be redesigned to answer focused questions important to clinicians while reducing healthcare costs.


  • Investigators did not have access to data before 2005 to evaluate existing trends.
  • There may be unmeasured factors affecting the use of limited and full TTEs.

This study was funded through VA HSR&D's Quality Enhancement Initiative (QUERI). Dr. Heidenreich leads MedSafe QUERI in Palo Alto, CA.

Sandhu A, Parizo J, Moradi-Ragheb N, and Heidenreich P. Association between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography. JAMA Internal Medicine. Research Letter. July 23, 2018;epub ahead of print.

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