Choosing Wisely alone not enough to drop low-value imaging of clogged neck arteries

Low-value imaging of clogged neck arteries persists in the nation’s largest integrated hospital system, despite strong advocacy against this practice.

That’s according to the results of a new investigation of value at the Veterans Affairs Health System, published Friday in JAMA Network Open. Back in 2013, Choosing Wisely and the American Academy of Family Physicians labeled such screening for carotid artery stenosis as unnecessary in patients without symptoms. The harms often outweigh the evidence, with imaging leading to unnecessary surgery and potential patient harm, the groups wrote.

Curious whether the VA heeded this advice, experts from several institutions studied data from more than 809,000 exams delivered between 2007 to 2016. They found that overall rates of carotid imaging remained stable those 11 years, with a small dip in one category that predated Choosing Wisely. It’s clear that building awareness alone will not change physician behaviors, lead author Timothy Anderson, MD, and colleagues advised.

“These findings suggest that to reduce low-value testing and utilization cascades, interventions targeting ordering clinicians are needed to augment the impact of public awareness campaigns,” Anderson, with the Division of General Medicine at Beth Israel Deaconess Medical Center, et al. wrote Sept. 4.

The research team targeted all imaging tests performed by VHA radiology departments to assess for carotid stenosis for their analysis. Those included ultrasound, MRI angiography, and CTA. They also utilized natural language processing to help pinpoint tests, as carotid imaging codes are nonspecific and could include other indications, they noted. And they sorted to identify such imaging specifically ordered for low-value indications such as screening, preop testing or fainting.

Bottom line: The rates remained relatively flat from 2007 to 2016. They observed a modest increase in imaging tied to fainting and small declines related to carotid bruits and preoperative imaging.

“To achieve success in reducing low-value carotid imaging, targeted interventions are needed,” the research team advised. “Quality improvement initiatives, including clinical decision support tools, clinician education, and direct feedback to ordering clinicians, have demonstrated promise in single-center and health system studies of other low-value testing.”

Read much more on their findings in JAMA Network Open here.