I'm always a bit skeptical when I come across an article suggesting that increased referrals to subspecialists is a good thing, especially when the authors are the subspecialists themselves. Here's a retrospective study, conducted by pediatric cardiologists, concluding that referral to a pediatric cardiologist can save money.
Source: Lang SM, Bolin E, Hardy S, et al. Diagnostic yield of outpatient pediatric echocardiograms: impact of indications and specialty. Pediatr Cardiol. 2017;38(1):162-169; doi:10.1007/s00246-016-1497-1. See AAP Grand Rounds commentary by Dr. David Spar (subscription required).
Before pediatric cardiologists jump all over me, remember that I'm a subspecialist too. The problem, particularly in a fee-for-service environment, is that all of us have implicit bias that might lead us to (subconciously) design and interpret research in a manner which benefits us.
In general, population quality of life in the US doesn't correlate very well with use of subspecialty consultations. Areas with higher concentrations of subspecialists, and subsequent increased utilization of those subspecialists, don't often have better healthcare outcomes but do have higher healthcare costs. This study, from a single children's hospital, looked at records over an almost 6-year period to compare the rates of abnormal findings present in echocardiograms ordered by pediatric cardiologists, other pediatric subspecialists, and primary care providers. Cardiologists seemed to utilize echos more efficiently than the other 2 groups. Cardiologist-initiated echos were abnormal in in 19% of children, compared to 14% for PCPs and 9% for subspecialists, which was statistically significantly different. Differences among the groups varied significantly based on the indication for the echo, with cardiac murmur showing the biggest difference in yield between cardiologists and the other 2 groups. The authors provided a convincing cost analysis to urge referral to a pediatric cardiologist rather than obtaining echocardiogram as a first step. However, I wish they had considered innovations like telemedicine, which could decrease costs particularly where pediatric cardiologists are located at a significant distance from the patient.
Of course, an echocardiogram often is used as a screening test, and some degree of normal results would be acceptable in order not to miss any significant pathology. A bit buried in the article, however, was the fact that some echos are ordered as baseline testing, to use as comparison to follow a disease process such as systemic hypertension, or perhaps use of a cardiotoxic medication. In this instance, a normal result is still useful and would not suggest the echo was unnecessary. These echos may be more likely to be ordered by subspecialists other than cardiologists.
Readers might be interested in another recent article on the subject, also retrospective but smaller and with slightly different methodology.
A key point of this whole discussion, however, is that thanks to a multi-organizational (including AAP) working group we now have Appropriate Use Criteria (AUC) for echocardiography in children. The retrospective study was performed prior to any impact the AUC might have had on clinical practice, and I certainly hope we see some follow up studies to determine the AUC's impact of echo utilization. I suspect that, if the AUC can be implemented effectively, both pediatric cardiology referrals and echocardiogram utilization could be reduced without increased risk to patients.
