Optimizing utilization of pediatric echocardiography and implications for telemedicine

Telemedicine can deliver tertiary level services to remote communities where subspecialty care is limited. Locally performed echocardiography has been initiated at several locations around Iowa. The goal of this study was to examine utilization and diagnostic yield of community-based echocardiographic services. Community physicians selected patients for remote echocardiograms (echoes), and studies were performed locally by sonographers trained in recording pediatric echoes. Echoes were sent to the pediatric echocardiography laboratory by mail or via telemedicine systems. Echoes were also ordered locally by pediatric cardiologists during outreach clinics in the same communities. Numbers of normal and abnormal echoes ordered by community physicians and pediatric cardiologists were compared by chi-square analysis. Since January 1996, community physicians ordered 378 echoes, whereas 154 echoes were ordered by pediatric cardiologists at outreach clinics. Stratifying echoes by patient age found that the percentage of normal studies in patients <1 year of age was no different between groups (27% normal by community physicians vs 15%; chi-square 0.92; p = 0.34). The percentage of normal studies ordered by community physicians was significantly greater in patients >1 year of age (83% normal by community physicians vs 25%; chi-square 80.2; p <0.0001). Thus, (1) community physicians effectively identified patients <1 year of age with abnormal echoes, (2) significantly fewer echoes may be required in patients >1 year of age if patients are first evaluated by a pediatric cardiologist, and (3) patient selection will impact cost effectiveness of remotely obtained echoes.