Comparison of Appropriateness and Cost of Echocardiograms Ordered by Pediatric Cardiologists and Primary Care Providers for Syncope
Background: Appropriate use criteria (AUC) address indications for an initial outpatient pediatric transthoracic echocardiogram (TTE), including the common indication of syncope. In many labs, these studies can be ordered by a pediatric cardiologist or primary care provider (PCP). TTEs ordered by PCPs have been shown to have lower rates of appropriateness in prior studies, but no study has compared pediatric cardiologists and PCPs in appropriateness and cost effectiveness for TTEs ordered for syncope.
Methods: Patients with TTE ordered by a PCP and patients seen by a pediatric cardiologist for primary diagnosis of syncope from November 2016-October 2018 were included. The number of TTEs ordered for the pediatric cardiology syncope patients was used to determine the ordering rate. Appropriateness of TTE indications were classified as appropriate, maybe appropriate, rarely appropriate, and unclassifiable; data was compared using chi-squared testing. TTE findings were classified as normal, incidental, and abnormal. TTE cost, cost of referral to a cardiologist, and EKG cost were estimated using the Healthcare Bluebook. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER) by comparing the cost of TTE and appropriateness rate for PCPs to the cost of TTE, ordering rate, appropriateness rate, EKG, and consultation fee for pediatric cardiologists.
Results: Included for analysis were 65 PCP-ordered TTEs and 311 pediatric cardiology outpatient consults for syncope, at which 55 TTEs were ordered (17.7%). When a TTE was ordered, pediatric cardiologists ordered a significantly lower rate of rarely appropriate TTEs compared to PCP (7.4% vs 61.5%, p<0.001). There were no abnormal studies for PCPs or pediatric cardiologists. Ordering rate for appropriate or maybe appropriate indications was 60.2% higher for pediatric cardiologists. Cost effectiveness analysis demonstrated savings of $249 per patient if PCP refers to cardiology compared to just ordering a TTE. When appropriateness as an outcome is taken into account, $413.68 is saved by referring to pediatric cardiology per appropriate TTE ordered using the ICER.
Conclusion: PCPs order more rarely appropriate TTEs for syncope compared with pediatric cardiologists. Even when accounting for consultation and EKG fees, it is significantly less expensive and more cost effective for a PCP to refer to pediatric cardiology rather than ordering a TTE.