The Ultrasound-Assisted Physical Examination in the Periodic Health Evaluation of the Elderly

Follow-up data were reported through October 9, 1998.

We confined the reporting of results to findings of the USA-PE that were not already known. If we found gallstones, for example, that were already documented we did not report them as a new finding.

Results

Of the 72 patients who completed the study, 28 (39%) were found to have 34 abnormalities on the USA-PE that were not noted during the PE. Seven of these abnormalities could not be confirmed by specialist examinations, leaving 22 patients (31%) with 27 abnormalities. The [Table] illustrates these, as well as the patient-specific findings and any corresponding interventions that occurred as a result. One of the 7 confirmed cardiovascular findings was treated (carotid endarterectomy) while the other 6 were assigned to be monitored. Three patients had previously undetected urinary retention and have subsequently been treated. Two patients were found to have a potentially cancerous tumor, and biopsies were performed. There was 1 diagnosis of endometrial cancer, and the patient has undergone surgery and chemotherapy. Nine renal cysts and 4 gallstones did not require further action.

Accuracy of Findings

Seven of the 34 abnormalities found were not confirmed by formal studies. The only finding known thus far to have been missed by the USA-PE is a case of aortic stenosis, also missed by both physicians during the PE. It was found during an echocardiogram that had been ordered to confirm mitral stenosis found during the USA-PE.

Costs

On the basis of known costs of leasing ultrasound equipment,32 hiring physicians in western New York,^33,34 and the time allocated for these examinations, the cost of performing a USA-PE is estimated at approximately $30 in addition to the costs of the conventional examination (generally 99205, 99215, or 99397). At $30, the additional cost of examining the 72 patients in this study would have been $2160 if the physician time and ultrasound machine had not been donated. Given the fees from our locale³⁵ for intravenous pyelogram, $90; transthoracic echocardiogram, $300; renal ultrasound, $80; carotid Dopplers, $170; abdominal sonogram, $110; thyroid sonogram, $80; and pelvic sonogram, $90, the costs of studies necessary to confirm USA-PE true positives totaled $2150, cost to refute false-positives, $1140. Adding these 2 costs together and distributing them over the 72 patients gives an additional cost of $45.69 per patient for the USA-PE. More costs were generated as some of the true positives required consultations, surgeries, hospitalizations, and other interventions, but those costs are not tallied here.

Discussion

In our study of 72 senior patients who had been under regular medical care, 22 (31%) were found to have previously undiscovered abnormalities revealed by USA-PE. Although many of these abnormalities did not seem clinically significant, others were of major importance, and their discovery led to interventions that were beneficial to the patients. Five patients (7%) had interventions for conditions discovered by the USA-PE, such as endometrial carcinoma, carotid endarterectomy, and various urologic interventions. Although some of these discoveries appeared to be a direct consequence of the application of ultrasound to the examination, in other cases, such as the distended bladders, the diagnosis might have been made with PE, although it was not by these examiners. Also, the instance of endometrial carcinoma would likely have been diagnosed without ultrasound screening, since the patient had reported vaginal spotting and the primary physician had initiated gynecologic referral. The USA-PE expedited these diagnoses in an efficient and accurate manner, however, and appeared to have prevented certain diagnostic errors.

Several patients had abnormalities discovered that did not lead to any immediate intervention, such as small aortic aneurysms, gallstones, and subcritical carotid lesions. Such discoveries may be beneficial if they stimulate regular surveillance and lifestyle changes. Balanced against these postulated advantages is the anxiety such knowledge might produce, though the risk of such anxiety is inherent in the process of comprehensive health evaluations. Previous work by our group³⁶ reported a high patient acceptance of ultrasound screening and a patient recommendation that it should become a routine part of the PE.

Ultrasound has been studied in the screening of all the organs accessed by the USA-PE, namely the carotids, thyroid, heart, abdomen, and pelvis, in most cases with some success demonstrated. In carotid screening, success has been mixed, with some claiming cost efficacy,8 and others disputing it.³⁷ Even so, reviewing data from Lee,³⁷ it appears that the problem with carotid screening is not so much the cost of the test but the marginal benefit to the treatment that follows a positive result (carotid endarterectomy).

Studies of thyroid ultrasound screening^9-12 have demonstrated a much higher incidence of abnormalities than is commonly found by PE. Filatov⁹ reported that 7.5% of the study population had thyroid abnormalities. Head to head with PE, Brander13 found that 43 of 77 nodules detected by ultrasound had escaped detection during PE. Fourteen of them exceeded 2 cm.