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British Society of Echocardiography

Echocardiography within the British Isles: A National Survey

John Chambers, Kevin Fox, Roxy Senior, Petros Nihoyannopoulos

Summary
Introduction Little information about echocardiography exists to guide future planning so we conducted a postal survey within the British Isles. A total of 196 surveys were returned giving a response rate of 80%. Results The annual total number of studies performed were: adult transthoracic 968,500; paediatric 16,325; transoesophageal (TOE) 18,525; stress 9800. There were 768 sonographers, 607 whole time equivalent sonographers and 374 specialist sonographers. On average each whole time equivalent sonographer performed 1689 studies. There were 345 high-end and 129 mid-range machines suggesting that on average each highend machine was being used for 2242 and each mid-range machine for 2078 transthoracic equivalents each year. There were also 150 portable systems. The waiting times were long with 62% of centres reporting a wait of more than 4 weeks for a routine transthoracic study and 23% more than 18 weeks. Waiting times were longer than 8 weeks for outpatient TOE in 16% hospitals and for outpatient stress echocardiograms in 49%. Conclusion Echocardiographic activity falls short of estimated demand suggesting that proposed government targets cannot be met without substantial changes A new system of screening echocardiography is a partial solution to the two-fold short-fall in transthoracic studies but must only be delivered by adequately trained and supported sonographers In addition at least 500 specialist sonographers are likely to be needed Each hospital should have at least one cardiologist trained and experienced in echocardiography to supervise services and deliver transsoesophageal and stress echocardiography Any echocardiography service whether delivered from community or hospital must include core components of trained staff, quality control, and specialist back-up. The models for providing these components will vary according to local need and current local provision.

Introduction
Echocardiography is a core hospital and community service necessary for the diagnosis and management of heart disease and also to assess the cardiac response to disease in other systems. It is needed for the diagnosis of heart failure and murmurs, for the assessment of patients before major noncardiac surgery, for patients on coronary care and intensive care units, and for patients receiving chemotherapy for cancer. It is widely acknowledged that echocardiography is under-resourced and incompletely developed, but standards and guidelines have only recently been published. These include British Society of Echocardiography recommendations for individual and departmental accreditation, NICE guidelines on heart failure (1), the Healthcare Commission investigation of heart failure services and the Department of Health 18 week wait target (2). In order to plan for the future it is helpful to define the starting point. Surprisingly little information about the current state of echocardiography exists. There have been a small number of regional or focused surveys (3,4), but none before has attempted a systematic overview of hospitals in the whole country.

Methods
A questionnaire was sent by post to the head of echocardiography at all 304 NHS hospitals in England, Scotland, Wales and N Ireland on a list obtained commercially. The form was also placed as a pdf on the British Society of Echocardiography web-site and made available at the annual conference in 2005. Finally a number of hospitals who failed to reply initially were contacted by telephone or in writing.
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A total of 206 surveys were returned. As a result of mergers, 19 forms were from two and 9 from 3 hospitals representing a response rate of 80%. However 10 hospitals had no echocardiography department leaving 196 forms for analysis. There were a further 23 returns from private hospitals but two were wings of tertiary centres who reported the figures for the whole hospital and these were excluded leaving 21 forms for analysis. An interim analysis of 156 NHS hospitals was performed to inform a British Cardiac Society working group on national variations on cardiological services and this is published separately (5). The results were entered onto an Excel database and analysed using the Excel software. Percentages were calculated based on the total number of forms replying to the individual question rather than the total number of returned surveys. The survey had tick-boxes for ease of completion, but this necessitated making assumptions for the purpose of calculations. For estimating numbers of echocardiograms performed or the numbers of sonographers, a figure midway through the range was used. Thus 34 hospitals had 1-2 trained sonographers giving an estimate of 34 x 1.5 or 51 sonographers. For those reporting > 5 sonographers the conservative assumption of 6 sonographers was made. Thus 54 centres had > 5 sonographers giving an estimated 324 sonographers. For > 5 machines the conservative assumption of 6 machines was made. For > 10,000 studies, the assumption of 11,000 was made; for > 200 TOEs, the assumption of 300 was made; and for > 200 stress studies, the assumption of 250 was made. For > 200 paediatric studies an assumption of 350 was made. For < 1000 transthoracic studies an assumption of 500 studies was made. A specialist sonographer was defined by spending more than 80% of time in echocardiography. For 4 or more specialist sonographers the assumption of 5 sonographers was made. A sonographer was defined as a noncardiologist performing echocardiograms and the term subsumes the terms cardiac physiologist, echocardiographer, radiographer and cardiac technician.

Results
Activity There was an out of hours echo service in 82 (43%) hospitals usually provided by the on-call cardiology SpR. Studies were performed for general practitioners in 133 (71%) usually as direct or open access studies. However in 19 there was a portable machine either in the community or taken from the hospital to the community. The modal number of adult transthoracic studies performed each year was 3-5000 (Table 1) and 67% of hospitals performed 3-10,000 studies. The estimated total number of studies performed in 191 hospitals was 968,500. In 158 (83%) hospitals, 90-100% of studies were performed and reported by sonographers, while in 26 (14%) centres only 50-90% of studies were performed by sonographers, in 4 (2%) centres only 10-50% and in 2 (1%) fewer than 10% of studies. An estimated total of 16,325 paediatric cases were performed in 87 (48%) centres (Table 2). Sonographers performed 90-100% of the studies in 41 of these (47%), but reported in only 30 (34%). In 7 (8%) centres, 50-90% of studies were performed by sonographers, in 14 (16%) centres 10-50%, and in 29 (33%) fewer than 10% of studies. Vascular studies were performed in 29 hospitals (Table 2). Table 1. Number of adult transthoracic studies performed each year < 1000 1-3000 3-5000 5-10000 >10000 36 (18 76 (39%) 55 (28%) 16 (8%) No of hospitals 8 (4%) Table 2. Approximately how many of the following does your department perform each year? 0 1-50 51-100 101-200 > 200 TOE 23 54 49 30 30 91 42 24 13 20 Stress 93 30 5 15 37 Paediatric 115 6 1 5 17 Other e.g. vascular
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Outpatient transoesophageal studies (TOE) were performed in 163 (83%) centres and stress echocardiograms in 96 (49%) (Table 2). An estimated 18,525 TOEs were performed which is 1.9% of the total transthoracic load. An estimated 9800 stress studies were performed or 1% of the transthoracic load. Intraoperative TOEs were performed in 39 centres of which 12 (31%) did fewer than 100, 9 (23%) did 101-250, 12 (31%) did 251-500 and 6 (15%) did more than 500 studies each year. In 24 (62%) centres studies were performed by anaesthetists, but in 7 centres only 50-90% were performed by anaesthetists, in 5 only 10-50% and in 9 fewer than 10%. Staffing levels A cardiologist was regularly involved in echocardiography in 158 (81%) centres, but only performed transthoracic studies in 135 (73%). The numbers of trained and whole time equivalent sonographers is given in Table 3. There were 47 centres with one sonographer specialising in echocardiography, 57 with 2, 21 with 3 and 28 with 4 or more. These results give an estimated 768.5 sonographers, 607 whole time equivalent sonographers and 374 specialist sonographers. Allowing that a TOE or stress study is 2 transthoracic equivalents in terms of time, there was a total of 1,025,150 transthoracic equivalents performed by 607 whole time equivalent sonographers or 1689 studies per sonographer. Table 3. Frequency of departments with sonographers by number 0 1-2 3-4 5 2 34 71 29 Trained sonographers 58 74 15 Whole time equivalent 6 sonographers >5 54 31

In the preceding two years, 1-2 sonographers had left in 82 departments and 3-4 in 19. The main exit was to another NHS post from 68 centres, the private sector in 18 centres, industry in 12, retirement in 9 and other in 25. More than 25% of posts were filled by agency staff in 26% of centres and in 38 (21%) of hospitals, more than 25% of posts were unfilled either by locum or permanent staff (Table 4). Table 4. Over the past two years what percentage of posts have been <10% 10-25% 25-50% > 50% 136 (73%) 21 (11%) 17 (9%) 12 (6%) Filled by agency staff 102 (56%) 41 (23%) 29 (16%) 9 (5%) Unfilled Training (Table 5) Most centres were involved in training both sonographers (81%) and SpRs (80%) and 25 centres had trained general practitioners and 35 other groups (mainly anaesthetists and staff grade doctors, but a small number of emergency, and elderly care physicians). Of the estimated 768.5 trained sonographers, 434 were BSE accredited. A conservative estimate of 55 sonographers were not trained via the cardiac physiology route (counting > 3 at 3 centres as 12 sonographers). There was a regular business or teaching meeting at 127 (69%) of centres and 86 (47%) reported formal quality control (e.g. 5% of all studies re-examined). Table 5. In the last two years how many of the following groups have been trained? 0 1-3 4-7 >7 35 141 13 0 Sonographer 38 111 38 4 SpR 168 25 0 0 GP 141 31 2 2 Other Waiting times Most departments (90%) triaged requests as urgent or routine. The majority of urgent inpatient transthoracic requests were performed on the same or the next day while most routine inpatient requests were performed within a working week. In 18% of centres, a routine study waited for more than a week (Table 6a). Although urgent outpatient requests at most centres were performed within 4 weeks, the wait was over 4 weeks in 21 (11%) (Table 6b). Routine requests waited longer with 62% of centres reporting a wait longer than 4 weeks and 23% longer than 18 weeks. Most
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requests for inpatient stress or TOE were performed within a week (Table 7a). However 39% of outpatient TOE and 74% outpatient stress waited longer than 4 weeks (Table 7b). Table 6a. Waiting times for inpatient transthoracic echo Same day Next day 143 (74%) 36 (19%) Urgent 13 (8%) 35 (18%) Routine 2-5 days 14 (7%) 108 (57%) > 5 days 0 34 (18%) > 18 weeks 1 (0.5%) 43 (23%)

Table 6b. Waiting times for outpatient transthoracic echocardiogram < 1 week 1-4 weeks 4-8 weeks 8-18 weeks 77 (41%) 91 (48%) 18 (10%) 2 (1%) Urgent 4 (2%) 25 (13%) 59 (31%) 59 (31%) Routine Table 7a. Waiting times for inpatient complex studies < 3 days 3-7 days 105 (65%) 52 (32%) TOE 27 (47%) 26 (45%) Stress 1-2 weeks 5 (3%) 4 (7%) 8-18 week 17 (12%) 19 (22%)

> 2 weeks 0 1 (2%) > 18 weeks 6 (4%) 24 (27%)

Table 7b. Waiting times for outpatient complex studies < 1 week 1-4 weeks 4-8 weeks 4 (3%) 82 (58%) 32 (23%) TOE 0 23 (26%) 22 (25%) Stress

Machines There were 345 high-end machines, 129 mid-range and 159 portable systems. The oldest system in regular use was upgraded less than 3 years previously in 62 (33%), between 3 and 5 years in 56 (30%), between 5 and 10 years in 58 (31%) and more than 10 years in 10 (5%). Assuming that all complex studies were performed on high-end machines, each machine performed 82 studies each year. Then assuming that the total 984,825 adult and paediatric cases were performed equally on all high-end and mid-range machines gave 2078 per machine. Allowing 2 transthoracic equivalents per complex study (approximately equivalent to the time taken) suggests that high end machines were performing 2242 and the mid-range machine 2078 transthoracic equivalents each year. There were 449 rooms compared with 474 high-end or mid-range machines (Table 8). Table 8. Centres having machines by size and number 0 1 2 7 38 66 High-end static (cost c 100,000 50 37 28 Mid-range (cost c 50,000) 42 86 21 Portable (cost c < 35000) 3 41 84 Rooms

3 37 7 7 29

4 16 1 1 20

5 6 1 0 5

>5 10 1 1 8

Private hospitals These hospitals performed fewer transthoracic studies than NHS hospitals, 14 (70%) less than 1000 each year, but 9 (43%) also performed TOE, 7 (33%) intraoperative TOE, 3 (15%) stress studies, and 6 (30%) paediatric studies. The estimated number of transthoracic studies was 15,000 assuming that < 1000 was 500 or 17,500 assuming that < 1000 was 750 and 22,000 assuming that <1000 was 999. An out-of-hours service was offered in 10 (48%) which is similar to the NHS, but only 5 (24%) performed studies for general practitioners. A regular business meeting was reported in 4 (19%) and quality control in 5 (24%), less than in the NHS. Waiting times were similar to the NHS for urgent inpatient requests but considerably shorter for routine inpatient (Table 9a) and all outpatient requests (Table 9b). Waits for complex studies were also short, all less than 3 days for inpatient TOE and stress studies. Waits for outpatient TOE were reported as < 1 week in 6 hospitals, 1-4 weeks in 2 and > 18 weeks in one. Waits for outpatient stress studies were reported as < 4 weeks in 4 although > 18 weeks in one. There were no sonographers at 2 hospitals, both performing fewer than 1000 studies each year. In the rest, there were 34 trained sonographers, 15.5 whole time
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equivalents and 8 specialist sonographers. Each whole-time equivalent sonographer performed an estimated 900 studies assuming a total of 14,000, 1030 assuming a total of 16,000 and 1290 assuming a total of 22,000. All three estimates are lower than for the NHS. Staffing problems were similar to the NHS. Six centres reported the loss of 1-2 sonographers, but none of 3-4 sonographers. These went to the NHS in 6 and to another private centre in 2. Three centres had 25-50% of staff and one had 1025% provided by agencies. There were 10-25% unfilled posts in 4 centres. A consultant cardiologist was regularly involved with echocardiography in 17 (81%), but did no transthoracic studies in 4 of these. Of the trained sonographers, 25.5 (75%) were BSE accredited. Three hospitals reported training 1-3 sonographers, one hospital 1-3 SpRs and one hospital 1-3 general practitioners. There were 19 high-end machines, 9 mid-range and 1 portable in 16 rooms dedicated to echocardiography. This equates to 535 studies each year per high-end or mid-range machine assuming a total of 15,000 studies or 786 assuming a total of 22,000 studies. Machines were newer than in the NHS. The oldest system in regular use was upgraded less than 3 years previously in 9 (45%), and between 3 and 5 years in 11 (55%), between 5 and 10 years in 58 (31%) and none more than 5 years previously. Table 9a. Waiting times for private inpatient transthoracic echocardiograms Same day Next day 2-5 days > 5 days 11 (58%) 5 (26%) 3 (16%) 0 Urgent 5 (26%) 10 (53%) 3 (16%) 1 (5%) Routine Table 9b. Waiting times for private outpatient transthoracic echocardiograms < 1 week 1-4 weeks 4-8 weeks 8-18 weeks > 18 weeks 15 (75%) 5 (25%) 0 0 0 Urgent 8 (42%) 10 (53%) 1 (5%) 0 0 Routine

Discussion
This survey with a response rate of 80% provides the most complete picture of echocardiography in the British Isles available to date to aid planning future services. The estimated number of transthoracic studies performed annually was 968,500 in 191 hospitals. It is difficult to estimate the total for the country, but this must be less than 1,489,410 which is the figure gained by taking the total of 304 hospitals and allowing for 10 not having echocardiography departments. This figure is still far short of the estimated potential demand for echocardiograms which is 42.8-47.7 per 1000 population or between 2,568,000 and 2,862,000 assuming a population of 60 million (6). It appears that about double the current number of studies may be required to meet estimated potential demand. An estimated 9800 stress studies were performed each year. Assuming a similar rate of performing stress studies (99 centres out of 190) in the non-responders, the maximum number could be 15,100. However the figure is likely to be closer to 9800. Even the maximum figure is far short of the estimated demand of 3.6 per 1000 population which equates to 216,000 (6), a 22-fold difference. For TOE, the total activity in this survey is 18,525 which suggests a national activity of 28,030. The estimated potential demand is 1.3 per 1000 population per year or 78,000 (6), an approximately threefold difference. Activity is failing to keep up with current demand as reflected in long reported waiting times. Although most urgent outpatient requests for transthoracic studies were performed within 4 weeks, the wait was longer than 4 weeks in 11.5% of hospitals. Routine requests waited longer with 62% of centres reporting a wait in excess of 4 weeks and 23% in excess of 18 weeks. Waiting times were shorter for TOE with 39% of hospitals reporting a wait longer than 4 weeks. This reflects a relatively low demand well balanced by cardiologists performing the technique. However 74% of hospitals reported a wait longer than 4 weeks for outpatient stress echocardiography (Table 7b) reflecting both high demand and a relatively small number of cardiologists trained and experienced in the technique.
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To deliver the current demand within acceptable waiting times as well as to accommodate estimated potential demand will require a number of changes. There could be some improvements in waiting times by better organisation of lists. However the 607 whole time equivalent sonographers in this survey are performing 1689 studies per year which is close to the BSE recommended mandatory maximum of 2000 and above the ideal of 1500 (7). Some of the demand could be accommodated by a new type of screening echocardiogram (8,9), which would be suitable for ruling out significant pathology in patients suspected of having heart failure, to confirm normal LV function in patients having surgery or cancer chemotherapy or to confirm that a murmur is a benign systolic flow murmur. Many echocardiograms will be performed in the community and an echocardiography service will be defined by a number of key requirements: the ability to provide high-quality screening, standard and complex studies; training and accreditation of all staff; quality control; refresher courses and continuing education; second opinions; and medical back-up. Where each of these components occur and who delivers them will vary locally. The British Society of Echocardiography has defined a screening echocardiogram and, in 2005, ratified a generic certification process for sonographers, general practitioners or practitioners with a special interest in cardiology. It is essential that screening echocardiographers have adequate entry qualifications, training and supervision. Although more echocardiography will need to be centred on the community, hospitals will remain essential for complex studies and usually for second opinions and medical back-up. However, although some demand may be taken up by noncardiac echocardiographers, there will also need to be an expansion in the number of sonographers and specialist cardiologists Within this workforce, the need for specialisation to maintain expertise in a highly skilled field is recognised by the fact that a substantial number of whole time equivalent sonographers, 434 of 768 (57%) are already specialist echocardiographers performing echocardiography for more than 80% of their work-time. The British Society of Echocardiography strongly supports maintaining the current pattern of directentry of science graduates into echocardiography as an alternative to progression via generic cardiac physiology. This allows the training of an echocardiographer in 2 years via the current system of accreditation compared with the absolute minimum of 4 years via the cardiac physiology route. There are already 55 sonographers who were not trained via the cardiac physiology route. This route of entry has also been approved in principle by the Department of Health. Up to 500 sonographers are likely to be needed initially given that there is a twofold difference between current activity and potential demand giving 750000 1,000,000 extra studies each year. There is also the need for recruitment of cardiologists specialising in echocardiography to perform specialist studies and to supervise the clinical activity of general departments. There is a gulf of over 200,000 stress studies between current activity and potential demand. The British Cardiac Society suggests the need for a total of 1494 imaging consultants (6). Initially the British Society of Echocardiography suggests at least 400 more echocardiography specialists, approximately two per centre, allowing that one can perform 450 stress studies per year. In fact 135 centres already have a cardiologist as clinical lead who performs transthoracic studies. If these were allowed to perform stress studies in the place of other duties, a large part of the 400 shortfall would be delivered. As a preliminary step, each hospital should have one cardiologist specialising in echocardiography as recommended by the fifth report (10). As well as a substantial need for more stress studies, there is a smaller need for more TOEs, but some of this demand could be accommodated by cardiac anaesthetists and intensive care specialists who increasingly are being trained in TOE. Although there appears to be some spare capacity in the private sector in terms of sonographer activity and machine numbers, this may not be true. A relatively large number of sonographers is necessary to allow short waiting-times. Timetabling maximum activity inevitably reduces the number of vacant slots available at short notice. Furthermore, these hospitals are still limited by the same insufficient sonographer pool as for the NHS and vacancies exist in the private sector as much as in the NHS. Established private hospitals are unlikely to be able to reduce waiting lists in the NHS.
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The number of machines in the NHS appears to be adequate for current activity with each machine performing slightly under the maximum number of 2500 suggested by the British Society of Echocardiography. However many are old and may allow suboptimal imaging; 36% were upgraded more than 5 years ago and 5% more than 10 years ago. Furthermore machine numbers do not include lack of availability as a result of machine failure or extended absence of a machine in an invasive laboratory, theatre or performing a ward-based study. To accommodate increased demand would require more machines although the current number of 159 portable systems could perform a large number of screening studies either in the hospital or the community. The sum of current activity, extra studies on portable systems and the studies from recruiting an extra 500 sonographers (up to 1 million) approximates to the estimated potential demand. The space given to echocardiography is anecdotally known to be inadequate and this survey lends support to this view since there were only 449 rooms compared with 474 high-end or mid-range machines. Limitations The response rate was 80% which is satisfactory. Despite this it is possible that the non-responders were less organised and more likely to be underachieving relative to the responders. It is also likely that BSE members were more inclined to reply so that the percentage of accredited sonographers may be an overestimate of the true national figure. There are other sources of inaccuracy. Tick-boxes were used in order to simplify the questionnaire to encourage response, but this led to the need to estimate absolute numbers. In particular, more hospitals than anticipated exceeded the upper end of the ranges. Finally the results are all self-reported and have not been checked or verified independently. Conclusion Current activity is well below actual demand and this is reflected in long waiting times. It is also far below potential demand particularly for stress echocardiography. We need a substantial number of new sonographers, as well as cardiologists and other practitioners specialising in echocardiography. These need to work in systems with essential components like training and accreditation, quality control, expert supervision, and continuing education. The models for providing these components will vary according to local need and current local provision. Substantial changes are necessary to deliver proposed government targets and clinical standards.

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