Healthcare costs have become a massive area of concern and discussion. The United States spends approximately $4.3 trillion each year for healthcare. There has been much discussion about how to bend the cost curve so as to continue providing high quality healthcare but at a more affordable price both for payers and for the patient. The answer is likely going to be multifactorial, but this gives each stakeholder in the of the house of medicine the opportunity to assess how to address cost. The challenge becomes, how can we manage costs without affecting the quality of care that patients receive? Or stated differently, can we trim waste and improve the value that the patient receives?
Point-of-care Ultrasound (POCUS) has become a ubiquitous part of providing care to patients in the modern era of medicine. It has been likened to the revolution of auscultation sparked by Rene Laennec in the early 1800s. Now, the stethoscope is as integral to the practice of medicine as analgesics and antibiotics. When introduced, this simple device began to allow physicians to peel away the obscuring effects of the skin and listen to the effects of disease. Fast forward to today, and ultrasound is doing the same thing. In the hands of a skilled clinician, POCUS allows physicians to peer deeply into the hidden recesses of patients and now see abnormal anatomy or see the disrupted physiology.
Previous studies have shown that POCUS can increase the specificity and accuracy of diagnoses and decrease patient testing time and throughput. However, as POCUS is becoming more common in patient care, an important question to ask is what are the effects on cost? Are the costs effects justified based on the value that it provides to the patient? The hypothesis is that POCUS, when employed early in the patient's ED/inpatient course, can paradoxically provide a cost benefit. This study looks to see if POCUS can be a vehicle to help improve costs and drive value for patients.
The Study
The study authors examined the effect of POCUS in a 213-bed community hospital when POCUS was performed in the ED. They observed the clinical care provided over 15 shifts that spanned across the spectrum of shifts in a given week. When an ultrasound was incorporated, they queried the physicians with the following three questions:
1. What did you expect to see on the ultrasound?
2. What would have been your next steps if you didn't have the ultrasound?
3. Did the results of the ultrasound change your clinical management?
The study authors recorded the data received as well as the workup avoided and assigned CPT codes for the items avoided as a result of POCUS use. The costs were then calculated for 3 different payers: CMS, Private insurance, and no insurance/self-pay. In this study, only ED costs were assessed. The primary outcome of the study was the direct cost savings associated with POCUS use. Secondary outcomes were indirect costs savings like throughput time and discomfort to patients.
The Results
In this study, 49 observations were made with approximately 33% resulting in a management change. Half of the ultrasounds that did not change management were performed for procedural guidance. On average, POCUS provided the following cost savings due to management changes:
- Private Insurance: $1134.31
- No Insurance/Self-pay: $2826.31
- CMS: $181.63
Using a 2 sample, 1 sided t test, the authors showed that the results were statistically significant for all categories. And when broadened out to show the results of all ultrasounds performed (not just the studies that changed management), the aggregate cost savings continued to be statistically significant.
Conclusions
Based on the results, the authors conclude that early use of POCUS (where indicated) in the ED results in a net cost savings for patients. Intuitively this makes sense. If we were to blindly apply a battery of tests to a patient, eventually we would come up with the right answer, but at what cost of time, unnecessary testing, and incidental findings? The more we can be focused with our testing strategy, the more quickly, accurately and cost effectively we will be able to manage patients. POCUS allows us to apply that focus. However, there are limitations to this paper. The authors highlight that this is a single center study and that there may be a degree of inclusion bias. I would also add that is difficult to estimate actual cost savings when the more expensive option never occurred. In this paper, the authors estimated the cost savings based on testing that didn't occur based on uptodate.com guidelines for management of the diagnosis that was avoided using POCUS. This is probably the best way to standardize the analysis for the purposes of the study, but it does not incorporate factors such as provider practice variability, costs of chasing incidental findings, costs associated with length of stay, etc.
Final Verdict
While this paper makes some assumptions in the methodology, I believe that the results reflect more signal than noise. POCUS has been shown in other works to increase diagnostic accuracy and decrease patient length of stay. These results should not be underestimated. If we begin pulling on that thread, it is not implausible to see that by employing a superior test, we can decrease the reliance on a battery of inferior tests as well as the time to it takes to benefit from the results. Thus, an appropriately healthy application of POCUS should decrease costs and improve value for patients.
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