Transthoracic Echocardiograms: are they cost-effective?

If you are even remotely connected to Cardiology, then you know: transthoracic echocardiograms (Echo's), along with electrocardiograms are the most frequently ordered exams and performed like Candy (in the words of Oprah "YOU get an Echo and YOU get an Echo and YOU get an Echo!"). As we shift more into outcomes-based care, we cannot help but wonder, are Echo's cost-effective or cost-saving? You would think by now, with the vast body of literature available, it would be extremely easy to obtain this kind of information...

Well, not so fast and apparently, not so easy! There is a paucity of data on the cost-effectiveness of Echos. Sure, there are some old studies assessing their cost-effectiveness in diagnosing cardiac diseases, but those were published in the '80s and '90s, where breakthrough therapies were not available, like transcatheter aortic valve replacement (TAVR), transcatheter edge-to-edge mitral valve repair using MitraClip (Abbott, IL, USA), medications for patients with heart failure like Entresto or chemotherapeutic agents and regimens for patients with cancers.

The question then becomes, how can we assess the cost-effectiveness of one of the most widely used imaging tests? This is crucial in critically appraising its role in the emerging era of value-based, outcomes-centered care. One way to go about this would be to extrapolate the cost-effectiveness by evaluating the cost-effectiveness of the pathologies and treatments which Echo's serve as the main means for diagnosis and for ruling in/out patient candidacy for therapies respectively. Data from two very big trials in patients with aortic stenosis (the PARTNER 1 and 2 studies) have shown that in patients with severe aortic stenosis, TAVR is cost effective for those at extreme surgical risk and at high risk and even more, TAVR is cost-saving in patients at intermediate surgical risk. Similarly, the economic substudy of the COAPT trial, which showed that MitraClip in patients with severe functional mitral regurgitation was superior to optimal medical care in terms of mortality, heart failure-related hospitalizations and quality of life, also showed that MitraClip was cost effective in the long-run in these patients (lifetime incremental cost-effectiveness ratio of $55 600 per quality-adjusted life-year gained).

In the worlds of heart failure and cardiotoxic chemotherapies, Entresto (sacubitril/valsartan) has been the only medication to come out in over a decade with a 20% improvement in the composite of cardiac death or heart failure(HF)-related hospitalization. This is extremely important given the expansive HF population. The stats are staggering: HF is known to affect 26 mil people worldwide, 5.8 mil people in the US and approximately 50% of patients diagnosed expire within 5 years of diagnosis. Studies done in the US, Europe (UK and Denmark) and South America (Colombia) have shown that Entresto is overall cost-effective, particularly in the long-run. With respect to patients receiving chemotherapy for cancer, particularly breast cancer in women (an estimated 3.8 mil women will be breast cancer survivors in the US in 2020), as well as hematologic malignancies (leukemias, lymphomas), TTEs are central for monitoring potential cardiotoxic effects of chemotherapy. Cardiotoxicity, meaning development of new heart failure, plays a critical role, because in certain cases, depending on the severity of cardiac dysfunction, life-saving chemotherapy may need to be withheld. In these dreadful situations, patients are facing a double-edged sword: getting sick and being at risk of passing from heart failure or succumbing to their cancer (when their chemotherapy has to be paused).

There is little data so far assessing the cost-effectiveness of regular TTEs pre-, during and post-chemotherapy. What we do know is that in the appropriately-selected patient population, baseline TTEs and strain assessment can both predict development of HF after chemotherapy initiation. Importantly, strain and LVEF are two parameters recommended by the ACC/AHA guidelines to be followed in patients receiving chemotherapy for monitoring for possible cardiotoxicity.

What all of this is telling us is that high quality TTEs have a central role in the assessment, selection and monitoring of patients across the entire spectrum of cardiac pathology. Performance of timely and high quality exams by skilled sonographers is indispensably linked to the cost-effectiveness of the modality.

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