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Clinical and Financial Impact of Ordering an Echocardiogram in Children with Left Axis Deviation on Their
Prasad Ravi1, Ravi Ashwath1, James Strainic1
1Division of Pediatric Cardiology, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Insights
Left axis deviation (LAD) on ECG is linked to congenital heart disease (CHD). A pediatric cardiologist's physical exam is highly accurate for detecting CHD, making echocardiograms cost-effective only when the exam is abnormal.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Diagnostics
- Electrocardiography
Background:
- Left axis deviation (LAD) on electrocardiogram (ECG) is often associated with congenital heart disease (CHD).
- This finding typically prompts further diagnostic testing, including echocardiograms (ECHO).
- The clinical utility and cost-effectiveness of routine ECHO for all patients with LAD require evaluation.
Purpose of the Study:
- To compare the diagnostic accuracy of physical examination (PE) by a pediatric cardiologist against echocardiogram (ECHO) findings in patients presenting with LAD on ECG.
- To assess the cost-effectiveness of performing ECHO on all patients with LAD on ECG.
Main Methods:
- Retrospective cohort study of patients with LAD (QRS axis ≥0° to -90°) on ECG.
- Inclusion criteria: age >0.25 and <18 years, non-postoperative, with both PE and ECHO performed by a pediatric cardiologist.
- Decision tree model used to analyze ECHO costs based on PE findings, with ECHO cost derived from 2014 Medicare reimbursement rates.
Main Results:
- 146 patients met inclusion criteria.
- Physical examination demonstrated high sensitivity (97%) and specificity (90%) for detecting cardiac abnormalities in patients with LAD.
- Cost to identify an ECHO abnormality was $8365 for patients with normal PE versus $263 for those with abnormal PE.
Conclusions:
- Physical examination by a pediatric cardiologist is highly sensitive and specific for identifying CHD in patients with LAD on ECG.
- Performing an ECHO is cost-effective only when the physical examination is abnormal.
- Not performing an ECHO in patients with normal PE carries a small risk (approx. 2%) of missing incidental structural cardiac disease.
Objective:
Left axis deviation (LAD) on the electrocardiogram (ECG) is associated with congenital heart disease (CHD), prompting the clinician to order further testing when evaluating a patient with this finding. The purpose is to (1) compare the physical examination (PE) by a pediatric cardiologist to echocardiogram (ECHO) findings in patients with LAD on resting ECG and (2) assess cost of performing ECHO on all patients with LAD on ECG.
Design:
An IRB approved, retrospective cohort study was performed on patients with LAD (QRS axis ≥0° to -90°) on ECG between 01/02 and 12/12.
Inclusion Criteria:
age >0.25 and <18 years, non-postoperative, and PE and ECHO by pediatric cardiologist. A decision tree model analyzed cost of ECHO in patients with LAD and normal/abnormal PE. Cost of complete ECHO ($239.00) was obtained from 2014 Medicare reimbursement rates.
Results:
A total of 146 patients met inclusion criteria with 46.5% (68) having normal PE and ECHO, 1.4% (2) having normal PE and abnormal ECHO, 47.3% (69) having abnormal PE and ECHO, and 4.8% (7) having an abnormal PE and normal ECHO. Sensitivity and specificity of PE for detecting abnormalities in this population was 97% and 90%. Positive and negative predictive value of PE was 91% and 97.5%. In patients with normal PE, the cost to identify an ECHO abnormality was $8365, and $263 for those with abnormal PE.
Conclusion:
In presence of LAD on ECG, the sensitivity, specificity, and positive and negative predictive values of PE by a pediatric cardiologist are excellent at identifying CHD. Performing an ECHO on patients with LAD on ECG is only cost effective in the presence of an abnormal PE. In the presence of normal PE, there is a possibility of missing incidental structural cardiac disease in approximately 2% if an ECHO is not performed.
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