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ULTRASOUND: WHAT'S WRONG WITH THIS PICTURE?

It's cheap and accurate in Europe--but not in the U.S.

It's a picture that lasts a lifetime: the first ultrasound image of a tiny fetus, floating securely in its fluid-filled cocoon. One, two, three, four, five fingers on each hand, five toes on each foot, the diminutive heart pulsing rapidly. For soon-to-be parents, ultrasound can be a calming tonic--or the first sign of serious trouble. To doctors, the procedure--used in some 70% of pregnancies, at a cost of $1 billion--can help date a pregnancy, aid in diagnosing birth defects, and reduce liability. But an important question remains: Does ultrasound have any real benefit as a routine tool to screen for problems in even low-risk pregnancies?

The issue involves both effectiveness and cost. A 1993 New England Journal of Medicine study called RADIUS, found that routine ultrasound scanning of a group of low-risk women provided no benefits in reducing neonatal deaths or reducing the incidence of moderate or severe illness. It detected more problems than were found in a similar group of unscanned women, but the information often came too late to be useful. And it is not inexpensive. About half of the $1 billion spent on ultrasound for pregnancy each year goes for routine screening. ''It fails miserably as a screening test,'' says Dr. Fredric D. Frigoletto Jr., chief of obstetrics at Massachusetts General Hospital in Boston and one of the study's authors.

QUESTIONS. Concern about how to make ultrasound more cost-effective is likely to increase with a new report on ultrasound in Europe. The study found that ultrasound screening in Europe was far more effective at identifying problems than screens done in the U.S. Also, the screening costs much less in Europe. The findings strengthen the case for ultrasound screening and raise questions about the way it is done in the U.S.

The European findings came from the so-called Eurofetus database, culled from 60 hospital ultrasound laboratories in 14 countries. The study showed that European doctors found fetal disorders at strikingly higher rates than their U.S. counterparts. Looking back at 3,685 infants born with birth defects, the study found that defects in 61.4% of the infants were detected by ultrasound screening--twice the rate found in the U.S. study. And 56% of those defects were detected within 24 weeks of pregnancy, when it is still legal for an American woman to have an abortion. (It's rare that anything can be done to correct birth defects.) In contrast, in the RADIUS study, just 17% of the defects identified were found by the 24th week.

Clearly, the benefits of ultrasound are realized only when it is done well. In the Eurofetus study, all sonograms were done in hospitals--usually by certified technicians. In the U.S., they're often done in doctors' offices. Even the RADIUS study, though it found a dismal U.S. detection rate overall, showed that hospitals and high-quality laboratories detected three times as many abnormalities as doctors' offices did. ''Ultrasound is extremely useful in experienced hands,'' says Dr. Mark I. Evans, vice-chairman of obstetrics and gynecology at Wayne State University in Detroit. ''In inexperienced hands, it's extremely wasteful.''

''WAKE-UP CALL.'' In the U.S., there are plenty of inexperienced hands. Any doctor can buy ultrasound equipment and begin scanning without any special training. ''RADIUS was a wake-up call in a lot of ways,'' says Dr. Beryl R. Benacerraf, clinical professor of radiology and obstetrics and gynecology at Harvard medical school. ''The quality of ultrasound should be improved.''

Steps are being taken to do this. The American Institute of Ultrasound in Medicine is sponsoring a voluntary accreditation program. And managed-care companies are devising their own accreditation policies, conducting site visits, and limiting reimbursement to expert facilities.

Doctors doubt that ultrasound will ever be as cheap in the U.S. as it is in Europe. With Europe's lower doctors' salaries and liability costs, the average cost of a routine sonogram there is $50, vs. $200 in the U.S. But rather than restrict women's access to the scans, it may be wiser to improve them so they can be read more easily. Limiting ultrasound to accredited centers could mean greater benefits for all--including peace of mind for prospective parents.

By Naomi Freundlich in New York



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