Although studies have shown that using echocardiography as a screening tool for the presence of congenital heart disease is not cost-effective, primary care physicians continue to do so. In an effort to understand their reasoning, a survey containing questions about their estimation of the cost of cardiology services and their approach to several brief clinical scenarios was sent to 867 pediatricians and family physicians in our area. 489 surveys were returned(56%). Data were analyzed using chi square tests, Cramer's V, Kruskal-Wallis ANOVAs and Spearman's r. 93% of the respondents underestimated the cost of an echo, and 67% overestimated the cost of cardiology referral. In fact, 57% of the respondents estimated that referral was as or more expensive than echo, when in reality echo is 3 to 4 times more expensive. 74% of the respondents felt that it was likely or very likely that a cardiologist would order an echo as part of the evaluation of a child with a murmur, when published studies and an analysis of our own practice pattern have shown that this is not the case. Only 25% said that it was likely or very likely that they would manage a patient with a simple defect (i.e. small VSD) found on echo without cardiology referral, suggesting that the echo is not ordered to avoid the need for specialist referral. Respondents were likely (r=0.43, p<0.001) to reconsider ordering an echo if a consult could be scheduled in 2 days rather than in several weeks, though this association was stronger for pediatricians(r=0.61) than family physicians (r=0.27). Family physicians were significantly(p<0.004) more likely than pediatricians to order echos to evaluate chest pain, syncope, an abnormal ECG, an abnormal CXR, or to exclude mitral valve prolapse.
Our survey suggests that the utilization of echocardiography by primary care physicians is in part due to a lack of understanding about the costs of cardiology services, a belief that cardiologists routinely obtain these studies, and the ability to get a diagnosis more quickly with echo. There is also evidence that family practitioners are more inclined to order these tests for a variety of indications than are pediatricians. Education about the cost of cardiology services and current cardiologist practice patterns may help to reduce the number of unnecessary and expensive tests.
