Mapping Echocardiographic Practice in Emilia-Romagna: A Regional Healthcare Census

Aims: To assess echocardiographic practice within a regional healthcare system. The Emilia-Romagna region, a high-performing, digitally advanced context, was therefore used as a "stress test" setting in which observed heterogeneity is unlikely to be overestimated. Methods: A region-wide census of echocardiography laboratories collected data on governance, staffing, workflow, digital infrastructure, and imaging capabilities. A 5-item structural-digital readiness index (0-5) included: Picture Archiving and Communication System (PACS) archiving, structured reporting, Electronic Health Record (EHR) integration, availability of advanced echocardiographic tools, and an appointment slot for transthoracic echocardiography (TTE) of ≥20 min. High quality was defined as ≥4. Logistic regression identified independent predictors. Results: Of 148 centers, 122 (82%) responded, reporting 294,156 TTEs in 2023 (range < 500 to >15,000 per center); 46% were accredited private centers. Public institutions showed greater digital maturity than private centers (p < 0.001), with higher PACS availability and structured reporting. Overall, 86% reported ≥ 20 min per examination. Advanced modalities were unevenly distributed: left ventricular strain (50%), 3D imaging (33%), and stress echocardiography (42%). Workforce limitations were common, with 80% of centers lacking sonographers. A high structural-digital readiness index (score ≥ 4) was achieved by 38 laboratories (31%) and was associated with digital infrastructure and advanced imaging (p < 0.001). In multivariable analysis, university affiliation (OR 8.2-9.1) and a designated echocardiography lead (OR 4.1) independently predicted high quality, whereas procedural volume was not independently associated with quality. Conclusions: Marked variability in echocardiographic infrastructure and quality persists despite an advanced organizational and technological context. Leadership and digital infrastructure are the primary determinants of quality.