Ultrasound in primary care assessed in Spain

In July 2019, the Health Technology Evaluation Service of the Basque County, OSTEBA, published a report titled “Indications, utility, and use of ultrasound in primary care.”

Ultrasonography can be defined as a diagnostic medical procedure based on images obtained by processing the echo signal received from body structures, generally using pulses of ultrasound waves. It is a rapid, safe, reliable, harmless and non-invasive technique that is well tolerated by patients, with relatively low associated costs, and in recent years, has become much more accessible thanks to smaller, more portable devices.

The report focuses on clinical ultrasonography, which refers to any situation where the clinician, a primary care provider, seeing the patient uses echography to complete their examination. Such scans are not exhaustive, seeking to detect and define any ultrasound finding; rather, they are focused only on the specific problem of interest.

The aim of the report was to assess the effectiveness, clinical utility, and efficacy of ultrasonography in primary care, define the clinical situations in which it should be applied, and the requirements for its use.

Methodology:

A search was conducted of the scientific literature with no time limit in databases that list publications on primary or secondary care and applied research, such as MEDLINE, Embase, the Centre for Reviews and Dissemination databases (HTA, NHS EED, DARE), the Cochrane Library and the National Guidelines Clearinghouse, seeking to identify publications that analyze the technique of interest.

Results:

From the literature search, five (5) articles were identified. Ultrasonography is a proven technology with good diagnostic performance when used by professionals with the appropriate skills and in populations where the prevalence of certain health problems and risk factors exceed given thresholds.

Several studies have concluded that the diagnostic skills, reliability, and performance of primary care clinicians seems to improve significantly when they add information obtained in ultrasonography to their usual diagnostic arsenal, helping to confirm or rule out various types of lesions or disorders.

Key studies and their findings are summarized here:

• A case series reported in the context of a theoretical and practical ultrasound training program for doctors, with a subsequent assessment of student competencies in obtaining the correct plane and detecting diseases in real patients, led to the conclusion that ultrasonography is an educational tool in medical training and does help enhance the physical examination
• A prospective study with 114 patients with abdominal pain concluded that primary care doctors that perform low-to-moderate complexity ultrasound examinations had a very high level of interrater agreement compared to that of specialists
• A prospective non-randomized study comparing radiographic examinations performed successively and independently by primary care doctors and radiologists concluded that primary care doctors are able to perform low-complexity abdominal ultrasound scans with diagnostic competence
• A prospective multicenter cohort of 1107 patients suggested that compression ultrasonography carried out by trained primary care doctors may be a good option in cases of suspected proximal deep vein thrombosis
• A pilot cohort study based on 106 patients concluded that, with adequate training, portable ultrasonography might be a useful and effective technique for screening for aneurysm of the abdominal aorta. Its good level of acceptance among patients, portability, safety, and high cost-effectiveness ratio mean that it may be considered an additional method for the assessment of cardiovascular risk

Economic evidence: A cost analysis was performed by the authors. This analysis found that the cost of primary care ultrasonography depends to a great extent on the costs of training courses and of the ultrasound systems used, the number of ultrasound examinations performed by primary care physicians per year and the time they spend on these examinations.

Although confirmatory evidence in the scientific literature was not found, according to personal communication with radiologists and primary care clinicians who have adopted the use of ultrasonography, the acquisition of sufficient skills to carry out the least complex procedures and identify more complex cases that should be referred requires not only formal training, but also hands-on experience with an ultrasound device, supervised or not, to complete an individual learning curve.

Conclusions:

• The use of ultrasonography in routine primary care medical practice seems to be a trend that will enable health professionals to improve the care provided to their patients
• The purpose of this type of imaging can immediately narrow the differential diagnosis based on the clinical information revealed by a traditional physical examination while refining clinical decision making for the subsequent management of the patient’s condition
• The economic analysis conducted helps us to understand the direct medical costs associated with ultrasonography and the contributing components

See the full report in Spanish with an abstract in English here.

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