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Point-of-care ultrasound shows diagnostic, cost-saving potential
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Point-of-care ultrasound provided diagnostic capabilities in several clinical areas and reduced costs, according to a systematic review recently published in Annals of Family Medicine.
“Point-of-care ultrasound is the future stethoscope for every clinician. Point-of-care ultrasound empowers the primary care physician by providing more diagnostic information or increasing precision in clinical procedures,” Camilla Aakjær Andersen, MD, of Aalborg University Fyrkildevej in Denmark, told Healio Primary Care Today.
She explained several potential benefits.
“The physician may bring the ultrasound scanner to the patient’s home to aid diagnosis, such as estimating if there is residual urine or ascites in a patient at the nursing home with an enlarged abdomen,” she said. “The physician may also use point-of-care ultrasound to guide simple clinical procedures, such as venous access or joint injections, as point-of-care ultrasound allows the physician to locate and follow the needle’s way through the tissue real-time on the screen. This way, precision improves.”
The 51 studies Andersen and colleagues reviewed reported that point-of-care ultrasound provided:
- for the heart, diagnostic accuracy sensitivity between 73% to 77% and specificity of between 75% to 85%;
- for the aorta, diagnostic accuracy sensitivity of 100% and specificity of 100%;
- for obstetric conditions, diagnostic accuracy sensitivity of 97% and specificity of 98%;
- for the lung, diagnostic accuracy sensitivity of 92% and specificity of 95%;
- for the kidney, diagnostic accuracy sensitivity of 82% and specificity of 99%;
- for other locations, such as musculoskeletal and urinary areas, diagnostic accuracy sensitivity of between 91% to 98% and specificity of between 83% and 95%.
False positives were reported in:
- 0.7% to 3.2% of obstetric examinations;
- 0.5% to 9.9% of abdominal examinations;
- 4% to 33.3% of all cardiac examinations;
- 93% of renal cell carcinoma examinations;
- 9.7% to 12.1% of broad health-check screenings;
- 18% of carotid artery screenings; and
- 21.4% of aorta screenings.
Neither learning to use point-of-care ultrasound, nor using it on patients, requires a significant amount of time, Andersen in the interview.
“Our review showed that competence in some simple examinations can be achieved after only a few hours of training,” she said. “Our review also showed that ultrasound examinations in primary care were not time-consuming — most examinations were performed in less than 10 minutes. Furthermore, ultrasound examinations seemed to be in line with patient preferences.”
As with most technologies, the price of point-of-care ultrasound has gone down, potentially enabling more PCPs to take advantage of the tool, Andersen said. The review also found 65.6% of point-of-care-ultrasound scans removed the need for further testing, and 83% of patients were willing to pay extra to have an ultrasound examination performed by a general practitioner, suggesting other potential cost-saving opportunities to its use.
Research independent of Andersen and colleagues’ findings suggest point-of-care ultrasound has not reached its full potential: A 2015 Family Medicine study found only 12.1% of 224 U.S. family medicine residency directors reported “familiarity with the literature that supports the use of point-of-care ultrasound” at a patient’s bedside besides obstetrical uses, and a 2017 Prescient & Strategic Intelligence press release reported the worldwide market for the device is expected to grow about 7% by 2025, due largely to the increasing number of older adults, growing occurrence of chronic diseases, and rising health care costs.
Andersen said there are some unknowns surrounding the device, which could set the stage for future research involving point-of-care ultrasound.
“Challenges remain in developing guidelines to support clinical decision-making attached to the use of point-of-care ultrasound in primary care and training programs aimed at primary care point-of-care ultrasound. We also need research that explores the long-term effects of this ultrasound in order to determine which examinations are best suited for primary care,” she said. – by Janel Miller
References:
Andersen CA, et al. Ann Fam Med. 2019;doi:10.1370/afm.2330.
Hall JWW, et al. Fam Med. 2015;47(9):706-11.
Prescient & Strategic Intelligence. Point-of-Care Ultrasound (PoCUS) device market to grow at 6.9% CAGR till 2025: P&S market research. https://globenewswire.com/news-release/2017/07/21/1055557/0/en/Point-of-Care-Ultrasound-PoCUS-Device-Market-to-Grow-at-6-9-CAGR-till-2025-P-S-Market-Research.html. Accessed Feb. 4, 2019.
Disclosures: Andersen reports no relevant financial disclosures. Please see the other studies for those authors’ relevant financial disclosures.
Perspective
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Mindy M. Horrow, MD, FACR, FSRU, FAIUM
Point-of-care ultrasound describes a focused ultrasound exam designed to answer a single question, specifically the presence or absence of a finding suspected on the physical exam or as guidance for a procedure. For instance, does a patient with a pulsatile abdominal mass have an abdominal aortic aneurysm or are the decreased breath sounds due to a pleural effusion? It is usually performed at bedside and is fundamentally different from a dedicated diagnostic ultrasound interpreted by an imaging specialist. The traditional diagnostic ultrasound involves certified training in the physics of ultrasound and use of the equipment, residency and/or fellowship training in the specialists’ area of medical expertise (radiology, cardiology, obstetrics and gynecology, etc.) with ongoing CME, a full and accessible recording of images, and an official report with conclusions and recommendations.
As ultrasound equipment has become smaller and cheaper, its use has proliferated widely among previously nonimaging health care providers. Increasing numbers of medical schools have incorporated ultrasound into their curricula. While this widespread use of point-of-care ultrasound has the goal of providing more rapid acute diagnoses, it also has the potential for harm. Ultrasound is a highly user-dependent imaging modality, compared to radiography, CT and MRI. Artifacts abound as well as both false positive and false negative findings, all of which may lead to further unnecessary imaging and testing as well as increased patient anxiety. A host of accreditation programs by major societies such as the American College of Radiology and American Institute of Ultrasound in Medicine have helped standardize and improve the quality of general diagnostic ultrasound imaging and interpretation.
The authors of this article are to be complimented on providing a review of the best literature in the field of point-of-care ultrasound performed by general practitioners. Unfortunately, they found that the articles are variable and nonuniform in their methods and conclusions, resulting in “low quality … mainly because of issues with design and reporting.” These issues make it impossible to make recommendations about the length and type of training necessary to perform a point-of-care ultrasound exam and how much these studies actually improve patient care or decrease the cost of health care. Whether point-of-care ultrasound reduces health care costs remains to be seen. Large prospective studies would be needed to address these issues.
The most important conclusion of this paper is that “Focused point-of-care ultrasound scans had higher diagnostic accuracy, were associated with less harm, and required less training.” In other words, a focused approach is reasonable for the general practitioner who has demonstrated competency in performing these scans.
Screening ultrasound exams should be avoided with a lesson taken from the proliferation of full body CT screening studies in the early 2000s. These studies ultimately failed due to unproven benefits and a high rate of incidental findings requiring expensive and often harmful follow-up procedures, according to previously published articles in The New York Times and the American Journal of Radiology. Lastly, there is always a potential for conflict of interest when the clinical physician is also the person who performs and interprets the imaging studies of their patients.
References:
Kolata, G. “Rapid Rise and Fall for Body-Scanning Clinics,” New York Times, Jan. 23, 2005
Stanley RJ. American Journal of Radiology. 2001;doi:10.2214/ajr.177.5.1770989.
Einstein Healthcare Network, Philadelphia
Sidney Kimmel Medical School,
Thomas Jefferson University, Philadelphia
Society of Radiologists in Ultrasound
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