In addition to providing excellent patient care, cardiologists must also prioritize lowering healthcare costs. Reducing wasteful spending will be a key driver of cardiology's economic sustainability moving forward, as overtreatment and low-value care account for $75.7 billion to $101.2 billion of healthcare's annual financial waste, according to JAMA.1 Investing in improving diagnostic accuracy through better ECG interpretation and other strategies can help cardiologists drive these costs down and improve patient care, saving money and, more importantly, lives.
The Multidimensional Costs of Diagnostic Errors
Misdiagnoses are a common challenge in cardiology. One study published in Diagnosis found missed or delayed diagnosis rates of 2.2% for MI, 8.7% for stroke, 19.9% for venous thromboembolism, 23.9% for arterial thromboembolism, and 27.9% for aortic aneurysm and dissection.2 More specific factors, such as sex-based differences or even unconscious racial biases, have the potential to drive further diagnostic errors if they are left unchecked.
Such errors are costly. Another study in Diagnosis showed that diagnostic errors related to the top 5 vascular diseases alone led to more than $500 million in malpractice payouts over a 10-year span.3
False positives are another common diagnostic mistake. One study in Revista Española de Cardiología found that among STEMI network activations, 14.6% were angiographic false positives, meaning no culprit artery was identified, and 11.6% were clinical false positives, meaning the discharge diagnosis was not STEMI.4
Since the average cost of angioplasty is around $32,000, according to the Chicago Tribune—atop the fact that it can be a dangerous procedure for patients who aren't indicated for it—false-positive results could drive up wasteful costs and worsen patient outcomes.5
Misdiagnoses can also raise the risk of malpractice and associated legal costs. A study of cardiology-related malpractice litigation published in Cureus showed that the two most common reasons for litigation were failure to treat (77.7%) and failure to diagnose (69.3%), with MI being the most frequently missed diagnosis.6 One 25-year study reported by Becker's Hospital Review quantified the inflation-adjusted cost of diagnostic error claims (as of 2016) at $386,849 per malpractice case.7
The Importance of Accurate ECG Interpretation
Investing in diagnostic ECG can make a substantial difference in caring for patients and reducing costs. As an efficient, lightweight, and affordable technology that can be available at the bedside, a 12-lead ECG can help ensure prompt and correct treatment when patients need it.
As with any other diagnostic technology, however, ECG accuracy depends on interpretation. If providers misread ECGs, it can negatively affect patient care and drive up unnecessary costs.
For example, one study in JRSM Cardiovascular Disease noted that up to 72% of unnecessary catheterization activations have been linked to ECG misinterpretation.8 At least in part, these misreadings may be due to the fact that ST elevations can present in other non-MI clinical contexts, such as pericarditis, myocarditis, right bundle branch block, stress cardiomyopathy (Takotsubo), acute vasospasm, and left ventricular hypertrophy, as a Cureus review notes.9
These misinterpretation rates should not undermine the utility of taking prehospital or in-hospital ECGs. The European Society of Cardiology recommends evaluating patients with suspected STEMI with a 12-lead ECG as soon as possible at the time of first medical contact in order to speed diagnosis and triage.10 If the results are unclear or don't support a diagnosis of MI, ECGs should be repeated and compared with prior readings whenever possible.
Providers should also take advantage of available resources for ECG interpretation from manufacturers, including educational materials and activities, given the significance of maintaining competency in ECG interpretation through continuous training.
Now more than ever, creative approaches to virtual learning may help bridge knowledge gaps as well. In a 2019 study of EMS personnel in CJC Open, for example, ECG diagnostic accuracy improved by 10.4% after the roll-out of an online case review program.11
Mitigating Healthcare Costs and Improving Patient Care
Given its large proportion of expenditures in relation to total healthcare costs, cardiology has a unique opportunity to cut unnecessary spending and drive revenue from value-based care simultaneously. With results available in minutes at the point of care, ECG, in experienced hands, has significant potential to drive down costs and improve patient care. Anthony Kashou, MD, also known as "The EKG Guy," stresses the importance of physicians becoming sufficiently trained in ECG interpretation to avoid putting themselves and their patients at a disadvantage.
Every minute is precious in cardiac care, and as healthcare practices and patients continue to reel from the economic effects of COVID-19, managing costs remains a critical consideration as well.
Resources
1. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. October 2019;322(15):1501-1509. https://jamanetwork.com/journals/jama/article-abstract/2752664
2. Newman-Toker DE, Wang Z, Zhu Y, et al. Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the "Big Three." Diagnosis. May 2020;8(1):67-84. https://www.degruyter.com/document/doi/10.1515/dx-2019-0104/html
3. Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: The "Big Three" – vascular events, infections, and cancers. Diagnosis. July 2019;6(3):227-240. https://www.degruyter.com/document/doi/10.1515/dx-2019-0019/html
4. Regueiro A, Fernández-Rodríguez D, Freixa X, et al. False positive STEMI activations in a regional network: comprehensive analysis and clinical impact. Results from the Catalonian Codi Infart network. Revista Española de Cardiología. April 2018;71(4):243-249. https://www.sciencedirect.com/science/article/abs/pii/S1885585717303055
5. Chicago Tribune. In the U.S., an angioplasty costs $32,000. Elsewhere? Maybe $6,400. ChicagoTribune.com. https://www.chicagotribune.com/lifestyles/health/health-fitness/sns-united-states-angioplasty-cost-20191227-fmbdrghgezazlfh2t6fg5r7ila-story.html. Accessed June 13, 2023.
6. Patel R, Rynecki N, Eidelman E, et al. A qualitative analysis of malpractice litigation in cardiology using case summaries through a national legal database analysis. Cureus. July 2019;11(7):e5259. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760876/
7. Becker's Hospital Review. The top seven analytics-driven approaches for reducing diagnostic error and improving patient safety. BeckersHospitalReview.com. https://www.beckershospitalreview.com/healthcare-information-technology/the-top-seven-analytics-driven-approaches-for-reducing-diagnostic-error-and-improving-patient-safety.html. Accessed June 13, 2023.
8. Degheim G, Berry A, Zughaib M. False activation of the cardiac catheterization laboratory: the price to pay for shorter treatment delay. JRSM Cardiovascular Disease. January-December 2019;8: 2048004019836365. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456844/
9. Khurana KV, Ranjan A. ST-segment elevation in conditions of non-cardiovascular origin mimicking an acute myocardial infarction: a narrative review. Cureus. October 2022;14(10):e30868. https://www.cureus.com/articles/117087-st-segment-elevation-in-conditions-of-non-cardiovascular-origin-mimicking-an-acute-myocardial-infarction-a-narrative-review#!/
10. Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal. January 2018;39(2):119-177. https://academic.oup.com/eurheartj/article/39/2/119/4095042
11. Huitema AA, Alemayehu M, Steiner OL, et al. Improving electrocardiography diagnostic accuracy in emergency medical services personnel. CJC Open. January 2019;1(1):28-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063641/
