Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging

Salomeh Keyhani, Eric M. Cheng, Ayman Naseri, Ethan A. Halm, Linda S. Williams, Jason M Johanning, Erin Madden, Soraya Rofagha, Alexandra Woodbridge, Ann Abraham, Rosa Ahn, Susan Saba, Elnaz Eilkhani, Paul Hebert, Dawn M. Bravata

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Abstract

IMPORTANCE National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES Indications for carotid ultrasoundswere extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS The mean (SD) age of this cohort of 4127 patientswas 73.6 (5.9) years; 4014 (98.8%) were male. Overall, therewere 5226 indications for 4063 carotid ultrasounds. The most common indications listedwere carotid bruit (1578 [30.2%of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8%of indications]). Multiple vascular risk factorswere the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imagingwere 5.4%(227 indications), 83.4%(3387 indications), and 11.3%(458 indications), respectively. Among the most common inappropriate indicationswere dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedureswere performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.

Original languageEnglish (US)
Pages (from-to)626-633
Number of pages8
JournalJAMA Internal Medicine
Volume176
Issue number5
DOIs
StatePublished - May 2016

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Carotid Stenosis
Veterans Health
Physicians
United States Department of Veterans Affairs
Carotid Endarterectomy
Vertigo
Transient Ischemic Attack
Syncope
Dizziness
Blood Vessels
Ultrasonography
Pathologic Constriction
Cohort Studies
Retrospective Studies
Stroke
Outcome Assessment (Health Care)
Organizations
Guidelines
Population

ASJC Scopus subject areas

  • Internal Medicine

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Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging. / Keyhani, Salomeh; Cheng, Eric M.; Naseri, Ayman; Halm, Ethan A.; Williams, Linda S.; Johanning, Jason M; Madden, Erin; Rofagha, Soraya; Woodbridge, Alexandra; Abraham, Ann; Ahn, Rosa; Saba, Susan; Eilkhani, Elnaz; Hebert, Paul; Bravata, Dawn M.

In: JAMA Internal Medicine, Vol. 176, No. 5, 05.2016, p. 626-633.

Research output: Contribution to journalArticle

Keyhani, S, Cheng, EM, Naseri, A, Halm, EA, Williams, LS, Johanning, JM, Madden, E, Rofagha, S, Woodbridge, A, Abraham, A, Ahn, R, Saba, S, Eilkhani, E, Hebert, P & Bravata, DM 2016, 'Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging', JAMA Internal Medicine, vol. 176, no. 5, pp. 626-633. https://doi.org/10.1001/jamainternmed.2016.0678
Keyhani, Salomeh ; Cheng, Eric M. ; Naseri, Ayman ; Halm, Ethan A. ; Williams, Linda S. ; Johanning, Jason M ; Madden, Erin ; Rofagha, Soraya ; Woodbridge, Alexandra ; Abraham, Ann ; Ahn, Rosa ; Saba, Susan ; Eilkhani, Elnaz ; Hebert, Paul ; Bravata, Dawn M. / Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging. In: JAMA Internal Medicine. 2016 ; Vol. 176, No. 5. pp. 626-633.
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abstract = "IMPORTANCE National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES Indications for carotid ultrasoundswere extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS The mean (SD) age of this cohort of 4127 patientswas 73.6 (5.9) years; 4014 (98.8{\%}) were male. Overall, therewere 5226 indications for 4063 carotid ultrasounds. The most common indications listedwere carotid bruit (1578 [30.2{\%}of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8{\%}of indications]). Multiple vascular risk factorswere the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imagingwere 5.4{\%}(227 indications), 83.4{\%}(3387 indications), and 11.3{\%}(458 indications), respectively. Among the most common inappropriate indicationswere dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0{\%}) received a carotid endarterectomy. Overall, 663 procedureswere performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.",
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T1 - Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging

AU - Keyhani, Salomeh

AU - Cheng, Eric M.

AU - Naseri, Ayman

AU - Halm, Ethan A.

AU - Williams, Linda S.

AU - Johanning, Jason M

AU - Madden, Erin

AU - Rofagha, Soraya

AU - Woodbridge, Alexandra

AU - Abraham, Ann

AU - Ahn, Rosa

AU - Saba, Susan

AU - Eilkhani, Elnaz

AU - Hebert, Paul

AU - Bravata, Dawn M.

PY - 2016/5

Y1 - 2016/5

N2 - IMPORTANCE National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES Indications for carotid ultrasoundswere extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS The mean (SD) age of this cohort of 4127 patientswas 73.6 (5.9) years; 4014 (98.8%) were male. Overall, therewere 5226 indications for 4063 carotid ultrasounds. The most common indications listedwere carotid bruit (1578 [30.2%of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8%of indications]). Multiple vascular risk factorswere the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imagingwere 5.4%(227 indications), 83.4%(3387 indications), and 11.3%(458 indications), respectively. Among the most common inappropriate indicationswere dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedureswere performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.

AB - IMPORTANCE National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES Indications for carotid ultrasoundswere extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS The mean (SD) age of this cohort of 4127 patientswas 73.6 (5.9) years; 4014 (98.8%) were male. Overall, therewere 5226 indications for 4063 carotid ultrasounds. The most common indications listedwere carotid bruit (1578 [30.2%of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8%of indications]). Multiple vascular risk factorswere the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imagingwere 5.4%(227 indications), 83.4%(3387 indications), and 11.3%(458 indications), respectively. Among the most common inappropriate indicationswere dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedureswere performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.

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