title: Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition.
abstract: OBJECTIVE
  The purpose of this study was to test the hypothesis that handheld ultrasound (HHU) provides a more accurate diagnosis than physical examination in patients with suspected cardiovascular abnormalities and that its use thus reduces additional testing and overall costs.
  
  
  BACKGROUND
  Despite the limitations of physical examination and the demonstrated superiority of HHU for detecting cardiac abnormalities, it is not routinely used for the bedside diagnosis of cardiac conditions.
  
  
  METHODS
  Patients referred for a standard echocardiogram for common indications (cardiac function, murmur, stroke, arrhythmias, and miscellaneous) underwent physical examination and HHU by different cardiologists, who filled out a form that also included suggestions for additional testing, if necessary, based on their findings.
  
  
  RESULTS
  Of 250 patients, 142 had an abnormal finding on standard echocardiogram. Of these, HHU correctly identified 117 patients (82%), and physical examination correctly identified 67 (47%, p < 0.0001). HHU was superior to physical examination (p < 0.0001) for both normal and abnormal cardiac function. It was also superior to physical examination in correctly identifying the presence of substantial valve disease (71% vs. 31%, p = 0.0003) and in identifying miscellaneous findings (47% vs. 3%, p < 0.0001). Of 108 patients without any abnormalities on standard echocardiography, further testing was suggested for 89 (82%) undergoing physical examination versus only 60 (56%) undergoing HHU (p < 0.0001). Cost modeling showed that HHU had an average cost of $644.43 versus an average cost of $707.44 for physical examination. This yielded a savings of $63.01 per patient when HHU was used versus physical examination.
  
  
  CONCLUSIONS
  When used by cardiologists, HHU provides a more accurate diagnosis than physical examination for the majority of common cardiovascular abnormalities. The finding of no significant abnormality on HHU is also likely to result in less downstream testing and thus potentially reduce the overall cost for patients being evaluated for a cardiovascular diagnosis.
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.
authors.forename: Manish
authors.initials: M
authors.lastname: Mehta
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.
authors.forename: Timothy
authors.initials: T
authors.lastname: Jacobson
authors.affiliation: Division of Biostatistics, Department of Biostatistics, Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon.
authors.forename: Dawn
authors.initials: D
authors.lastname: Peters
authors.affiliation: Portland Veterans Administration Medical Center, Oregon Health & Science University, Portland, Oregon.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Le
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.
authors.forename: Scott
authors.initials: S
authors.lastname: Chadderdon
authors.affiliation: Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.
authors.forename: Allison J
authors.initials: AJ
authors.lastname: Allen
authors.affiliation: Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Caughey
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon. Electronic address: kauls@ohsu.edu.
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Kaul
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017046:Cost Savings; D015150:Echocardiography, Doppler / Q000191:economics / Q000295:instrumentation; D004867:Equipment Design; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010808:Physical Examination / Q000191:economics; D019095:Point-of-Care Systems; D011446:Prospective Studies; D055815:Young Adult
keywords: cardiac diagnosis; handheld ultrasound; physical examination