Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Focus clinical ultrasonography: again competency differs from the patient outcome

Dear Editor,

We read with great interest the article recently published on JAMA Network Open by Ximena Cid-Serra et al. about the effect of a multiorgan focused clinical ultrasonography (FCU) on length of stay (LOS) in patients admitted to the internal medicine unit with a cardiopulmonary diagnosis [1]. The authors concluded that when multiorgan FCU is added to the initial clinical examination and compared to standard care without FCU, there is no difference in hospital LOS, incidence of readmission within 30 days, and general costs.

The aim of this letter is to comment on whether, based on the conclusion of this study, FCU should be considered a positive, neutral, or harmful tool for this court of internal medicine patients, because the conclusions may become important for readers.

Our first comment is that the treating team of the study performed a standardized FCU assessment with detailed reports without any consequent standardized recommendation on how to modulate the patient’s management. Second, in the study by Ximena Cid-Serra et al. shortness of breath was the most common presenting complaint of the population enrolled, present in 207 patients (83.4%), and our attention was caught by the fact that no one of these patients exhibited cardiac diastolic dysfunction; this result sounds not usual as it is well known that about 50% of patients with congestive heart failure have preserved ejection fraction. The difference between the two diagnoses may have an influence on the outcome. Third, this study used a single FCU examination without any repetition during the time course of the patient’s management, which is beyond the main principles and philosophy of point-of-care ultrasound. In our humble opinion, these three points are main concerns that undermine the conclusion but even the general layout of this study.

In the literature, few studies have shown that any diagnostic tool can improve a patient’s outcome without a treatment protocol or a specific goal to reach; we may cite the example of the goal-directed therapy guided by hemodynamic monitoring tools [2]. Mozzini et al. reported that repeated lung ultrasound examinations impact the patient management by reducing the hospital LOS of 1 day in patients with acute decompensated heart failure (ADHF) admitted to the internal medicine ward [3]. We also know from the literature that longer hospital stays are not related to better clinical outcomes in ADHF [4]. Of note, there is also no evidence that reducing the cost of care will improve the clinical outcomes in patients with ADHF. More likely, the outcome is strongly influenced by the clinical setting, the hemodynamic situation and the intervention done, and partially by the institution, country, and the technological level of the healthcare system where the patients are cared.

Thus, should we draw a negative interpretation of these results and conclude that FCU has no influence in the patient’s management in the clinical setting where these authors operate? Probably this is a wrong conclusion, as in literature many data support different conclusions. Moreover, it is not always useful and even not appropriate to test the effect of diagnostic tools on the clinical outcome. For instance, we do not know any randomized controlled trial showing that transesophageal echocardiography can improve patient’s survival in a cardiac surgery setting or other trials proving that pulse oximetry has an influence on perioperative events [5, 6]. Similarly, tube feeding lacks demonstration of meaningful benefits in patients with advanced dementia [7]. Nevertheless, no one can debate their use. Clinical benefits from many medical devices in specific clinical contexts are not proved by evidence but remain intuitive, and clinicians take many decisions under conditions of uncertainty [8]. In the case of ultrasound, putting competence into practice yields high performance, which does not necessarily imply an advantageous patient outcome.

Availability of data and materials

Not applicable.


  1. Cid-Serra X, Royse A, Canty D et al (2021) Effect of a multiorgan focused clinical ultrasonography on length of stay in patients admitted with a cardiopulmonary diagnosis: a randomized clinical trial. JAMA Netw Open 4(12):e2138228

    Article  Google Scholar 

  2. Mayer J, Boldt J, Mengistu AM, Röhm KD, Suttner S (2010) Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care 14(1):R18

    Article  Google Scholar 

  3. Mozzini C, Di Dio PM, Pesce G et al (2018) Lung ultrasound in internal medicine efficiently drives the management of patients with heart failure and speeds up the discharge time. Intern Emerg Med 13(1):27–33

    Article  Google Scholar 

  4. Philbin EF, Roerden JB (1997) Longer hospital length of stay is not related to better clinical outcomes in congestive heart failure. Am J Manag Care 3(9):1285–1291

    CAS  PubMed  Google Scholar 

  5. Porter TR, Shillcutt SK, Adams MS et al (2015) Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 28(1):40–56

    Article  Google Scholar 

  6. Moller JT, Johannessen NW, Espersen K et al (1993) Randomized evaluation of pulse oximetry in 20,802 patients: II perioperative events and postoperative complications. Anesthesiology 78(3):445–453

    Article  CAS  Google Scholar 

  7. Finucane TE, Christmas C, Travis K (1999) Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 282(14):1365–1370

    Article  CAS  Google Scholar 

  8. Chaitoff A (2021) Uncertainty in medicine. JAMA Intern Med 181(10):1416–1417

    Article  Google Scholar 

Download references




Not applicable.

Author information

Authors and Affiliations



LV and MV conceived the commentary and wrote the manuscript. SMM critically revised the manuscript and coordinated LV and MV work. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Marco Ventin.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vetrugno, L., Ventin, M. & Maggiore, S.M. Focus clinical ultrasonography: again competency differs from the patient outcome. Ultrasound J 14, 8 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: