QJM Advance Access published online on February 15, 2008
QJM, doi:10.1093/qjmed/hcm135
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Transthoracic echocardiography: a survey of current practice in the UK
From the 1Glasgow Royal Infirmary, 2Stobhill Hospital, Glasgow, 3Royal Infirmary, Edinburgh and 4Western Infirmary, Glasgow, UK
Address correspondence to Dr Mark C Petrie, Department of Cardiology, Glasgow Royal Infirmary, Glasgow G31 2ER. email: mcp1n{at}udcf.gla.ac.uk
Received 26 September 2007 and in revised form 15 November 2007
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Summary |
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Background: Echocardiography is one of the cornerstones of cardiovascular investigation. The escalating demands on echocardiography services necessitate close examination of how we organize our departments on a day-to-day basis, in order to provide a consistent, high-quality service.
Aim: To evaluate current transthoracic echocardiography practice in the UK.
Design: National postal survey.
Methods: A questionnaire was sent to the chief cardiac physiologist (CP) of every hospital in the UK with echocardiographic facilities.
Results: Three hundred and thirty six echocardiographic departments were identified. One hundred and twenty six (37.5%) completed questionnaires were returned. In 87% of hospitals, CPs both performed and reported over 80% of echocardiograms. Fifty-seven percent of CPs and 22% of doctors performing echocardiography held an accreditation in echocardiography. Only 60% of hospitals had formal criteria that had to be met prior to an operator being allowed to report echocardiograms unsupervised. Fewer than half of hospitals regularly audited their echocardiography service. Both outpatient and inpatient waiting times for echocardiography were highly variable and frequently excessive. Fewer than half of hospitals used modern techniques for assessing diastolic function, mechanical dyssynchrony or severity of mitral regurgitation.
Conclusions: In the UK, many transthoracic echocardiograms are performed and reported by operators without formally assessed competence. Fewer than half of hospitals regularly audited their service or used modern echocardiographic techniques. Services are likely to be improved by developing and instituting mandatory national guidelines.
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Introduction |
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Echocardiograms are requested by general practitioners, physicians in all branches of general medicine, cardiologists and cardiothoracic surgeons. The number of transthoracic echocardiograms has increased rapidly over the last decade. The results of echocardiograms are key to the diagnosis and management in a host of cardiac conditions. Measurement of left ventricular systolic function is used to determine whether certain drugs are indicated and assessment of valve function contributes to the decision-making about surgery. Echocardiography is also used to guide cardiac resynchronization therapy. The escalating demands on echocardiography services necessitate close examination of how we organize our departments on a day-to-day basis, in order to provide a consistent, high-quality service. Our aim was to evaluate current transthoracic echocardiography practice in the UK.
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Methods |
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A questionnaire was sent to the chief cardiac physiologist in every hospital in the UK. As no central database is available we telephoned every hospital in the country listed on the National Health Service website (n = 1066) to establish which hospitals did, and which did not, have echocardiographic facilities. The data were collated and analysed using Access and Excel software (Windows XP Professional, Microsoft Corporation, Seattle, WA).
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Results |
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Respondents
In the UK, 336 hospitals had echocardiographic facilities. One hundred and twenty six (37.5%) questionnaires were returned. Of all hospitals that had echocardiographic facilities, 34% were teaching hospitals, 56% were DGHs and 10% were community hospitals. Those that responded were representative: teaching hospital 30%, DGH 62% and community hospitals 8%.
Number of echocardiograms performed
The median number of echocardiograms performed at each institution per year was 3500 (Range 150–21 500; 25% centile: 2830, 75% centile: 5000). The mean number of echocardiograms performed on one machine in a morning list was seven (range: 2–15; SD 2.6) and in an afternoon list was six (range: 0–15; SD 2.6). A morning list contained nine or more studies in 23% of hospitals. Appointment times were adjusted for the complexity of examination in 30% of hospitals.
Staffing of echocardiographic departments: who performs and reports echocardiograms?
Cardiac physiologists
Cardiac physiologists performed echocardiograms in 98% of hospitals, and reported them in 88%. In terms of workload, cardiac physiologists performed and reported over 80% of all echocardiograms in 87% of hospitals (Table 1). In 26%, ‘all’ echocardiograms are performed and reported by cardiac physiologists.
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A median of four cardiac physiologists performed echocardiography. Each had a mean of 9.5 years (SD 3.7) experience in echocardiography. Fifty-seven percent held an accreditation in echocardiography, in 88% this was British Society of Echocardiography accreditation and in 12% this was with the Registration Council for Clinical Physiologists
Doctors
Most hospitals (85%) employed at least one doctor capable of performing echocardiography. The median number of doctors performing echocardiography in these hospitals was three, with a mean of 8.3 years (SD 5.3) experience in echocardiography. Twenty-two percent held echocardiographic accreditation, the majority with the British Society of Echocardiography (91%). Of all the echocardiograms carried out, 9% and 12% were performed and reported by doctors, respectively.
Criteria for reporting
Only 60% of hospitals had formal criteria that have to be met prior to an operator being allowed to report echocardiograms unsupervised. Of these hospitals with formal criteria, 80% required cardiac physiologists to hold British Society of Echocardiography certification prior to being allowed to report echocardiograms.
Continuing education
A regular forum for discussion of echocardiograms was held in 72% of hospitals. This occurred on average every 3.5 weeks. Most cardiac physiologists (81%) had attended a national echocardiography conference, and 18% an international conference in the preceding 3 years.
Quality control
Only 48% of the hospitals performed regular audit of echocardiography scans and reports.
Waiting lists
Inpatient
The median inpatient waiting time for an echocardiogram was 2 days. Twenty-one percent of hospitals had an inpatient waiting time of five or more days.
Outpatient
The median outpatient waiting time for an echocardiogram was 8 weeks (Figure 1). Twenty-two percent of hospitals had an outpatient waiting time of four or more months.
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Echocardiographic technique
Diastolic function assessment
Ninety-two percent of hospitals included assessment of diastolic function in routine examinations. Of those centres, 22% measured E:A ratio alone. Only 37% used tissue Doppler techniques to quantify diastolic function.
Dyssynchrony assessment
Cardiac dyssynchrony was assessed in 71% of hospitals (Table 2). Of these, 29% performed ‘eye-ball’ dyssynchrony assessment alone. Tissue Doppler techniques were employed in 39% of centres.
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Mitral regurgitation assessment
Thirty-nine percent of hospitals measured proximal iso-velocity surface area (PISA), 18% measured vena contracta and 6% assessed regurgitant volume.
Stress echocardiography
Less than a third of hospitals (31%) performed stress echocardiography on a regular basis. Fifty-six percent of those hospitals performed 
10 stress echocardiograms on a monthly basis.
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Discussion |
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Echocardiography is used in the diagnosis of many cardiac conditions and influences decisions regarding drug therapy, complex pacemaker therapies and cardiac surgery. Good-quality echocardiographic assessment is essential, with suboptimal quality leading to suboptimal management.
Staff performing and reporting echocardiography
In the UK, the majority of echocardiograms were performed and reported by experienced cardiac physiologists. Just over half (57%) of these experienced technicians held a formal echocardiographic accreditation. Remarkably, only 22% of doctors who performed echocardiograms held such an accreditation. In 40% of units, there were no formal criteria to identify when an operator should be allowed to report echocardiograms without supervision.
We have established that many echocardiograms were performed and reported by operators whose skills had not been formally assessed. Accreditation with an echocardiographic body is not mandatory within the UK. The only published national guidelines defining required skill levels for performing or reporting echocardiograms unsupervised are over 12 years old.1 Without assessment it is impossible to ensure an operator has accumulated the appropriate knowledge and necessary skills during training. Formal examination is the only way to guarantee minimum standards. Assessment by and accreditation with an echocardiographic body should be mandatory for all persons reporting echocardiograms unsupervised.
Once competency in performing and reporting an echocardiogram is established, continued education is vital. National guidelines should define core standards essential for maintaining competency.
Quality control
Fewer than half of echocardiography departments (48%) had formal quality-control mechanisms. We believe departments should audit the acquisition and reporting of at least 10% of all echocardiograms. Echocardiography meetings are educationally useful, but often only ‘interesting’ echocardiograms are reviewed. This is not a substitute for systematic audit and internal validation. No guidelines exist to direct quality control in echocardiography departments.
Waiting lists
There is marked national variation in waiting list times. In one in five hospitals, waiting times were 1 working week for inpatients and 4 months for outpatients. Long waiting lists prolong hospital admissions, increase expenditure and delay introduction of appropriate treatment. National guidelines setting limits for inpatient and outpatient waiting times would improve care.
Echocardiographic techniques
Either through lack of equipment, time or training many hospitals do not use advanced echocardiographic techniques.
Diastolic function
Although over 90% of hospitals routinely assessed diastolic function, a fifth relied on E:A ratio alone. While no method of assessing diastolic function is universally accepted, E:A ratio is widely recognized to be an inadequate assessment.2
Advanced echocardiographic techniques
The CARE-HF trial of cardiac resynchronization therapy included patients on the basis of echocardiographic dyssynchrony.3 Numerous methods for assessing dyssynchrony have been proposed but none yet has a clear role in patient selection.4 Techniques vary considerably in the hospitals surveyed. One-third of hospitals used ‘eye-ball’ assessment of dyssynchrony alone, while 39% employed tissue Doppler imaging.
Assessment of mitral regurgitation
Surgical treatment of mitral regurgitation has advanced rapidly. Accurate assessment of the severity and mechanisms of mitral regurgitation is thus increasingly important. Only a minority of hospitals routinely used robust techniques such as PISA to assess severity.
Current guidelines
The American Society of Echocardiography has issued guidelines on the minimum standards required for a cardiac sonographer.5 They state that to achieve minimum standards of competence, a cardiac sonographer should be accredited. The guidelines also define both continuing volume and medical education requirements to maintain competency.6 Accreditation is only mandatory in some states.
There are no formal European guidelines regarding the practice of transthoracic echocardiography. Voluntary accreditation is available with the European Association of Echocardiography.7 However, they state that ‘While European Accreditation is designed to test the competency of an individual to be able to perform, interpret and report routine echocardiographic studies unsupervised, the right to report and sign clinical studies in individual countries will be defined by national laws and regulations.’
The UK (in common with many other countries) has no formal published guidelines for the practice and implementation of transthoracic echocardiography. The British Society of Echocardiography does provide a certification process for individuals and departments. This is not, however, mandatory in the UK. The British Society of Echocardiography states on its website that ‘Accreditation is run as a service for members of the British Society of Echocardiography and is not a compulsory or regulatory certificate of competence or excellence.’8
The standard echocardiography service
We would suggest that the following forms the minimum requirements of an echocardiography service:
- All operators reporting echocardiograms should hold a professional accreditation;
- formal quality-control procedures should be in place; and
- there should be waiting time limits for both in and outpatients echocardiograms.
Few of the units surveyed would meet these criteria. We believe that such minimal requirements should be mandatory. Instituting such standards would prove challenging in the short term but would clearly result in improved cardiological care in the long term. Hospitals without echocardiographic services (almost 2/3 in the UK) should be networked to others able to provide a quality service.
Contrast with other cardiological procedures
In the UK, the British Cardiovascular Intervention Society has produced guidelines for the practice of percutaneous intervention.9 Regular, specified audit is collected by this body from all sites performing percutaneous intervention. We believe that quality imaging is as important as quality revascularization.
Limitations
We sent surveys to every hospital in the UK in an attempt to ensure complete coverage of all echocardiography departments. We were surprised that no database of hospitals with echocardiographic facilities exists held either by the NHS, the British Society of Echocardiography or British Cardiac Society. A central register of all departments is essential for developing a regulated national network. Clearly, we would have preferred a higher percentage of replies. We are, however, satisfied that the response rate of almost 40% allows us to comment on transthoracic echocardiography services that cover a large proportion of the population.
The voluntary nature of all surveys introduces bias. Departments who consider themselves ‘centres of excellence’ may regard the survey as unnecessary. Conversely, such departments may more readily reply, hoping to portray an effective echocardiography service.
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Conclusions |
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TopSummaryIntroductionMethodsResultsDiscussionConclusionsReferences |
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In the UK, many transthoracic echocardiograms are performed and reported by operators without formally assessed competence. Fewer than half of hospitals regularly audit their service or use modern echocardiographic techniques. Services are likely to be improved by developing and instituting ‘mandatory’ national guidelines. Guidelines should address the training, accreditation and continuing education of all individuals performing and reporting transthoracic echocardiography. They should also provide a framework for departments to ensure quality service provision.
Conflict of interest: None declared.
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References |
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1. Training in echocardiography – guidelines produced for the British Society of Echocardiography. Br Heart J (1994) 71:2–5.
2. Petrie MC, Hogg K, Caruana L, McMurray JJ. Poor concordance of commonly used echocardiographic measures of left ventricular diastolic function in patients with suspected heart failure but preserved systolic function: is there a reliable echocardiographic measure of diastolic dysfunction? Heart (2004) 90:511–7.
3. Cleland JGF, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med (2005) 352:1539–49.
4. Hawkins NM, Petrie MC, MacDonald MR, Hogg KJ, McMurray JJ. Selecting patients for cardiac resynchronization therapy: electrical or mechanical dyssynchrony? Eur Heart J (2006) 27:1270–81.
5. Bierig SM, Ehler D, Knoll ML, Waggoner AD. American Society of Echocardiography minimum standards for the cardiac sonographer: a position paper. J Am Soc Echocardiogr (2006) 19:471–4.[CrossRef][Web of Science][Medline]
6. Quinones MA, Douglas PS, Foster E, Gorcsan III, Lewis JF, Pearlman AS, et al. ACC/AHA clinical competence statement on echocardiography: a Report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence Developed in Collaboration with the American Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, and the Society of Pediatric Echocardiography. J Am Coll Cardiol (2003) 41:687–708.
7. last accessed 26th September 2007. http://www.escardio.org/bodies/associations/EAE/accreditation/TTE/.
8. last accessed 26th September 2007. http://www.bsecho.org/index.php?option=com_docman&task=docclick&bid=193.
9. Dawkins KD, Gershlick T, de Belder M, Chauhan A, Venn G, Schofield P, et al. Percutaneous coronary intervention: recommendations for good practice and training. Heart (2005) 91(Suppl. VI):1–27.
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