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Improving evidence base around carotid testing may reduce use of low-value imaging
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Clarification of current guidelines and development of decision support tools may improve the evidence base around carotid testing and reduce the use of low-value imaging, according to a new report in JAMA Internal Medicine.
Salomeh Keyhani , MD, MPH, associate professor of medicine at University of California, San Francisco, and staff physician at San Francisco Veterans Affairs Medical Center, and colleagues analyzed medical records of 4,127 Veterans Health Administration patients who underwent carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. The researchers’ aim was to develop a greater understanding of the underlying reasons asymptomatic patients aged 65 years and older receive carotid imaging. The mean age of patients was 73 years, and 98.8% of the cohort was male. The most common comorbidities were hypertension (88.2%), diabetes (39.6%) and atrial fibrillation (10.9%).
In total, 5,226 indications for 4,063 carotid ultrasounds were extracted from the medical records. Trained abstractors identified the indications for carotid ultrasound and a panel of experts deemed the appropriateness of the imaging.
The most common indications were for carotid bruit (30.2%) and follow-up for carotid disease in patients with previously documented carotid stenosis (20.8%). Only 5% of the indications were deemed appropriate, 83.4% were given an uncertain ranking and 11.3% were given an inappropriate ranking. Dizziness/vertigo and syncope were the most common inappropriate indications. Of the 4,063 patients who received an ultrasound, 83% had a carotid endarterectomy and 16.8% had carotid stenting. Rates of survival did not differ significantly based on the appropriateness of the imaging indication.
“The [U.S. Preventive Services Task Force] has an overall recommendation against any screening in asymptomatic carotid populations, whereas the guidelines issued by the American Heart Association in conjunction with other specialty societies recommend screening and follow-up for carotid disease in patients with carotid bruit and also patients with greater than 50% stenosis,” the researchers wrote.
“Revisiting the evidence base and clarifying, expanding and harmonizing the guidelines for imaging in asymptomatic populations may be warranted to reduce potentially unnecessary testing.”
Larry B. Goldstein
In a related editorial, Cardiology Today Editorial Board member Larry B. Goldstein, MD, from the Kentucky Neuroscience Institute at the University of Kentucky, recommended the use of “specific educational programs, the use of alerts embedded into the electronic health record and audits with feedback” and other interventions, which “may be helpful in reducing inappropriate testing.”
According to Goldstein, one of the most difficult issues was determining how to handle those tests that were conducted for reasons the panel of experts labeled uncertain.
“In the setting of uncertainty, a conservative approach to screening and referral to a center participating in a relevant clinical trial seems the most appropriate strategy,” Goldstein wrote. – by Tracey Romero
Disclosure: The researchers and Goldstein report no relevant financial disclosures.
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