The changing relative contribution of operator salary and hardware costs to echocardiography — A historical perspective

Abstract

There is a significant mismatch between the demand for and provision of echocardiography [1], leading to waiting lists, even for inpatients [2]. Becoming a fully accredited echocardiographer requires time-consuming initial and ongoing training in order to develop and maintain competency [3]. Our own experience is that echo hardware has developed rapidly both in terms of portability and affordability. In this articlewe quantify the relative changes in cost of both operator salary and echo hardware over time. To obtain the historical list prices of echo hardware, we contacted several of the major manufacturers (Toshiba, Siemens, Hitachi, Philips, GE) but we found that none were able to supply historical pricing information. Hence, our method was to conduct a search using google.co.uk, diagnosticimaging.com and the freelibrary.com for press releases dating back to1989using the terms “[manufacturer's name]AND (scanner OR ultrasound OR echo) AND (price OR cost) $ [year] release”, where the items [manufacturer's name] and [year] represent the individual manufacturer names and years from 1989 to 2010. We employed a strategy using US dollars, since equipment prices have been conventionally stated inUSdollars, and theUSAhas traditionally been the largest singlemarket. Using this search strategywe identified158models, of which 59 had both launch prices and year of launch available. These machines are listed in online supplement Table 1. Where a range was provided, we took the midpoint of this range. We did not convert the prices from US dollars to any other currency as this would have introduced artifactual variation due to a fluctuating exchange rate rather than reflecting progress in the affordability of hardware. Using the cheapest machine launched in 1991 as a baseline at 100, we mapped the change inprice of the cheapest availablemachine. In anyoneyearweused the price of the cheapest machine launched between 1991 and that year. We ascertained UK National Health Service echocardiographer salaries from government documentation. The Department of Health Advance Letters for Professional and Technical Staff [4] provided salaries from 1992 to 2004 when echocardiographers were paid on a national scale at levels MTO4 and above. Agenda for Change pay circulars to NHS employers [5] provided salaries from 2005 to 2010when echocardiographers were paid on the current national scale known as Agenda for Change at a level of Band 6 or above [6,7]. This information is listed in online supplement Table 2. The results indicate that salary costs, when adjusted for inflation, have fallen from 1992 to 2010 by 53%, as shown in Fig. 1. The decline in the price of the most affordable hardware is much greater, falling 93% between 1992 and 2010, also shown in Fig. 1. The relative costs of echo hardware and staffing have changed significantly over the last 20 years; hardware prices have fallen whilst salary costs have increased. There is now a wider range of equipment available including some devices with more limited functionality. However, only 7 of the 59 devices we found prices for lacked Doppler capability and all had 2D and colour flow mapping. Removing these devices had only minimal effects on the shape of the graph. In the future, training and salary costs are likely to be the ratelimiting step in providing echocardiography to all those who might benefit from it. It may be useful to develop strategies to facilitate and enhance the ability of non-specialists to safely use cardiac ultrasound to answer specific questions such as quantifying left ventricular function, so that the opportunities arising from price improvements in technology are not foiled. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2013.01.266.