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Original Investigation
May 2016

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging

Author Affiliations
  • 1San Francisco Veterans Affairs Medical Center, San Francisco, California
  • 2Division of General Internal Medicine, Department of Medicine, University of California San Francisco
  • 3Department of Neurology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
  • 4Department of Neurology, University of California Los Angeles
  • 5Department of Ophthalmology, University of California San Francisco
  • 6Veterans Health Administration Health Services Research and Development Service Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
  • 7Department of Neurology, Indiana University School of Medicine, Indianapolis
  • 8Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
  • 9Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 10Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
  • 11Department of Surgery, University of Nebraska Medical Center, Omaha
  • 12Omaha–Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
  • 14Puget Sound Veterans Affairs Medical Center, Seattle, Washington
  • 15School of Public Health, University of Washington, Seattle
JAMA Intern Med. 2016;176(5):626-633. doi:10.1001/jamainternmed.2016.0678

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 ultrasounds were 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 patients was 73.6 (5.9) years; 4014 (98.8%) were male. Overall, there were 5226 indications for 4063 carotid ultrasounds. The most common indications listed were 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 factors were the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imaging were 5.4% (227 indications), 83.4% (3387 indications), and 11.3% (458 indications), respectively. Among the most common inappropriate indications were dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedures were 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.