Echocardiograms used 20 percent less in low-risk patients with health plan prior authorization programs, according to study in Managed Care

First study to compare frequency of testing among risk groups

CHICAGO/WILMINGTON, Del. – Echocardiograms — frequently used in diagnosing and managing heart disease — were used 20 percent less in low-risk populations with health plans requiring prior authorization for the test, according to a study published in Managed Care.

The study, conducted by outcomes research company, HealthCore, for AIM Specialty Health compared the use of transthoracic echocardiograms among three risk subgroups within two larger groups — those whose health plans used a cardiac utilization management program and those whose health plans did not.

“While UM programs are well-established in the marketplace, this marks the first published study in a peer-reviewed journal to demonstrate that a UM program can promote the appropriate use of echocardiograms,” said Thomas Power, MD, FACC, AIM medical director and a practicing cardiologist. “This study shows that a cardiac UM program was used as it was intended, to eliminate coverage of medically unnecessary or inappropriate testing.”

UM programs apply health plan medical policies and clinical guidelines to determine if the proposed tests and procedures are eligible for coverage under the member’s health benefit program. The AIM Specialty Health clinical review criteria are based on American College of Cardiology Foundation’s Appropriate Use Criteria for echocardiography.

The study showed a 15 percent decrease in utilization of echocardiograms relative to a geographically matched control group. Of the tests that did not meet UM coverage criteria, the largest proportion (79 percent) came from low or medium risk population segments.

“This study is the first to compare risk levels among geographically matched populations with required prior authorization to those that did not have the echocardiography program,” said Andrea DeVries, director of research operations for HealthCore. “This level of study allows us to be more precise in separating out market trends from the program impact, as well as segment the population by risk group.”

Cardiovascular imaging procedures represent 29 percent of all medical imaging. Yet, studies published in 2010 and 2011 indicate that approximately 15 percent of cardiac imaging exams are inappropriate based on criteria established by the American College of Cardiology.

“At first glance, echocardiography would not appear to be a preferred subject of imaging management,” said Power. “But when one looks at the downstream impact — in terms of outcomes and costs to health systems — its use has so many repercussions that UM program review is justified.”

Echocardiography, a sonogram of the heart, is one of the most widely used diagnostic tests in cardiology. At least one previous study has shown that inappropriate use of the test can lead to unnecessary follow-up tests, including myocardial perfusion imaging and cardiac CT scans, exposing patients to more radiation, and procedures such as angioplasty and bypass surgery which also carry additional patient risks.

Overall, this recent study published in the November 2013 edition of Managed Care found that the UM group avoided three tests per 1,000 members when compared to the group without UM review.

Data from the HealthCore Integrated Research Database were used for health plan members in Indiana, Kentucky, Missouri, Ohio and Georgia, from October, 2008 through Sept. 30, 2011. Members were followed for one year before and one year after the implementation period.

About HealthCore, Inc.

HealthCore, based in Wilmington, Del., is the clinical outcomes research subsidiary of WellPoint, Inc. HealthCore has a team of highly experienced researchers including physicians, biostatisticians, pharmacists, epidemiologists, health economists and other scientists who study the “real world” safety and effectiveness of drugs, medical devices and care management interventions. HealthCore offers insight on how to best use this data and communicates these findings to health care decision-makers to support evidence-based medicine, product development decisions, safety monitoring, coverage decisions, process improvement and overall cost-effective health care. For more information, go to

About AIM Specialty Health AIM

Specialty Health is focused on driving appropriate, safe and affordable care through the healthcare system. For more than 35 million members covered across 50 states, D.C. and US territories, AIM targets the quality and cost of clinical services including radiology, cardiology, oncology, specialty drugs and sleep medicine. As a national leader in specialty benefits management, AIM helps health plans and their providers and employers focus on the value of health decisions with an integrated suite of solutions that combines clinical excellence, technology and superior customer service. AIM is a wholly owned subsidiary of WellPoint, Inc. (WLP).

Media Contact:
Lori McLaughlin, 317.488.6898

Related Articles