SPECIAL CONTRIBUTION Imaging the Heart: Cardiac Scintigraphy and Echocardiography in U.S. Hospitals (1983) Stephen J. McPhee and Deborah W. Garnick Division of General Internal Medicine, Department of Medicine, and Institute for Health Policy Studies, University of California, San Francisco, California The rapid growth of cardiac catheterization has raised questions about the availability of less costly, "noninvasive" tests such as cardiac scintigraphy and echocardiography. To assess their availability and rates of use, we surveyed 3,778 non-federal short-term U.S. hospitals in June, 1983. Overall, 2,605 hospitals (69%) offered 201TImyocardial perfusion scans, 2,580 (68%) MmTc equilibrium gated blood pool scans, and 2,483 (67%) cardiac shunt scans; 1,679 hospitals (44%) offered M-mode and/or 2-dimensional echocardiography, and 768 (20%) pulsed Doppler echocardiography. Volumes of procedures varied enormously among hospitals capable of performing them. High volumes of both scintigraphy and echocardiography were performed in a small number of hospitals. Larger, voluntary, and teaching hospitals performed higher volumes of both procedures. Despite widespread availability of these "noninvasive" technologies, high volumes of both cardiac scintigraphy and echocardiography procedures are concentrated in a small number of U.S. hospitals. J NucíMed 27:1635-1641,1986 CCardiac imaging by scintigraphy and echocardiog variety of applications. After one-dimensional (M- raphy have been among the fastest growing diagnostic mode) echocardiography was introduced, the equip technologies in medicine during the past 15 years (1,2). ment and technology made rapid progress (2). The Because there has been no previous examination of development and evolution of two-dimensional (2-D) national data, we undertook this study to examine the real-time echocardiography in the late 1970s provided presence of these technologies in U.S. hospitals. higher resolution images and better diagnostic sensitiv Following development of the basic technology for ity (2,3). More recently, the pulsed Doppler and contin nuclear medicine in the late 1950s and 1960s, rapid uous wave ultrasound techniques have been developed growth in its clinical applications occurred during the and applied to 2-D echocardiography (2,4). 1970s. Between 1971 and 1975 the use of all nuclear Though there has been no direct examination of the medicine procedures per 100 hospital admissions nearly growth of cardiac imaging, estimates from marketing doubled. In 1978, 6.5 million nuclear studies were surveys and manufacturers have suggested an extraor performed in the U.S.; by 1981, the number had grown dinarily rapid diffusion of these technologies. In 1978 to 9.7 million scans (/). Cardiac scintigraphy became an estimated 227,000 cardiac scintigrams were per possible in 1975 when the first practical computer formed in the U.S.; by 1981, this estimate had grown systems for technetium-99m (WmTc)equilibrium gated to 1.5 million scans per year (7). Pozen and colleagues, blood pool scans became available. In 1977, the Food extrapolating from a survey of a stratified sample of and Drug Administration approved thallium-201 (2("TI) 200 U.S. hospitals, estimated that by 1979 2,106 hos as a myocardial imaging agent, enabling the perform pitals had the technical capabilities to perform cardiac ance of perfusion and redistribution scans (7). scintigraphy (5). In 1982 the Office of Technology Diagnostic ultrasound blossomed in the mid-1970s Assessment (OTA) estimated that about half of the with the introduction of instruments permitting a wide 7,100 hospitals in the U.S. had nuclear medicine de partments capable of performing cardiac scintigraphy (7). The use of echocardiography has also increased rapidly, at an estimated rate of more than 30% per year Received Dec. 16. 1985; revision accepted Apr. 4. 1986. For reprints contact: Stephen J. McPhee. MD. Div. of General between 1979 and 1982. This growth was probably a Internal Medicine. 400 Parnassus Ave.. A-405, San Francisco. CA result of the development of the 2-D echocardiogram. 94143-0320. Though the rate slowed somewhat thereafter, it remains Volume 27 •Number 10 •October 1986 1635 substantially greater than that of many other diagnostic and, if so, the estimated number of certain procedures technologies (2). performed during the month before the survey: 2°'T1 This study was undertaken to assess directly the myocardial perfusion scans, 99mTcequilibrium gated extent of diffusion and rate of use of these "noninva- cardiac blood pool scans, and cardiac shunt studies. For sive" cardiac imaging modalities in U.S. hospitals by the first two procedures, stress/exercise and redistribu 1983. We examined: tion/rest tests were counted as separate studies even if •The proportion and types of hospitals that had performed on a single patient. They were also asked cardiac scintigraphy and echocardiography by about the availability in their hospital of several types 1983; of equipment, including scintillation camera, nuclear •The extent of utilization of six representative pro medicine computer, and computerized analysis of ven cedures, including :"'T1 perfusion and redistribu tricular function. tion scans, ''9mTc equilibrium gated blood pool In the section on echocardiography, hospitals were scans, cardiac shunt scans, M-mode echocardiog asked if three types of equipment were available, and, raphy, 2-D echocardiography and pulsed Doppler if so, the estimated number of procedures performed in 2-D echocardiography; the month before the survey: real-time units with 2-D •The organizational and ownership characteristics sector scans, dedicated cardiac M-mode units, and of hospitals offering these procedures; built-in or added-on pulsed Doppler units. Portable •The availability of equipment needed to perform equipment used by multiple hospitals was not included. such imaging; and Also, each hospital was asked if certain specialists •The relationship of hospital staffing and recruit were on its staff (cardiologists, cardiovascular surgeons, ment activities to such imaging. nuclear medicine specialists) and if such specialists had The data provide indirect evidence of the extraordi been recruited during the previous three years. narily rapid diffusion of these new "noninvasive" tech American Hospital Association Annual Survey, 1982. nologies by 1983. This survey provided data on such hospital character istics as size, regional location, ownership, and medical school affiliation (7). The American Hospital Associa MATERIALS AND METHODS tion defines hospital ownership as state or local govern In order to study the distribution and use of cardiac ment, voluntary (short-term, general, non-profit, com imaging modalities in the U.S., we conducted a national munity), or proprietary (for-profit) hospitals. survey of non-federal short-term general hospitals and other special hospitals (6). The responses to the ques RESULTS tionnaire items relating to cardiac nuclear imaging and echocardiography were analyzed and the results are Cardiac scintigraphy is offered by 69% of U.S. hos reported below. Information from the American Hos pitals responding to the survey. Overall, 2,605 hospitals pital Association's annual survey (7) also contributed (69%) offer 2°'T1myocardial perfusion scans, 2,580 to the findings in this study. (68%) offer WmTcequilibrium gated blood-pool scans, Survey of Specialized Clinical Services, 1983. A fif and 2,483 (66%) cardiac shunt studies. Cardiac scintig teen-page questionnaire, designed to obtain informa raphy is reported by three-quarters (75%) of voluntary tion on the availability and utilization of selected spe hospitals, but only by about two-thirds (64%) of pro cialized clinical services, was mailed to all 5,898 short- prietary hospitals and slightly more than half (56%) of term general hospitals in the U.S. in June 1983; 3,778 state and local government hospitals. As might be ex hospitals (64%) responded by September 1983. Al pected, hospitals affiliated with medical schools are though the survey was mailed to the chief executive much more likely (90%) than non-affiliated hospitals officer of each hospital, the instructions suggested that (65%) to offer these procedures. Larger hospitals are it be routed to specific department heads for comple more likely to offer cardiac scintigraphy; over 80% of tion. The respondents are similar to the entire universe 100-199-bed hospitals and over 90% of 200-299-bed of U.S. hospitals in terms of ownership, census division, hospitals perform these tests. A surprising percentage of and availability of standard hospital facilities (such as small hospitals offer cardiac scintigraphy; even among emergency departments or maternity care services). hospitals with only 50-99 beds, over 50% have this However, a slightly higher response rate among larger capability. hospitals means that we have proportionately more M-mode or 2-D echocardiography is offered by 1,679 complete information about those larger hospitals (44%) of U.S. hospitals responding to the survey. Pulsed (>100 beds) that are also more likely to have nuclear Doppler echocardiography is offered by only 768 (20%) imaging or echocardiography facilities (6). of respondents. Echocardiography is reported by half In the section on cardiac nuclear imaging, hospitals (52%) of voluntary hospitals, but only by 39% of pro were asked if they performed scintigraphic procedures, prietary and 40% of state and local government hospi- 1636 McPhee and Garnick The