Screening Ultrasound Exams Should Not Be Limited

February 2, 2012

The more advanced and more complicated the disease process, the more likely the patient will end up with surgery and/or amputation, increasing the cost of initial care and the additional intervention.

In a recent article about ultrasound screening tests, two physicians point out inconsistencies with the recommendations for using these examinations. For example, they quite rightly point out the U. S. Preventive Services Task Force (USPSTF) recommends against using these types of examinations, because there is "moderate high certainty that the service has no net benefit or the harms outweigh the benefits."

However in another discussion on the USPSTF website, with respect to carotid artery stenosis and screening, the following can be found:

“High-quality studies of the true prevalence (rather than the ultrasonography-based prevalence) of clinically important CAS in usual primary care populations are needed. Other research gaps include 1) evidence for a validated, reliable risk stratification tool that would allow us to distinguish those people who might benefit from screening from those who would more likely be harmed, 2) evidence on improved screening strategies that do not generate many false-positive results and unnecessary harms, and 3) further studies on confirmatory strategies that do not lead to additional harms.”

This raises real and potential concerns that screening for carotid artery stenosis may be an area of concern, however since we don't know the true prevalence, we can't be certain.

With ankle-brachial indices, also mentioned in the article, the following can be found on the USPSTF site: "The USPSTF found fair evidence that screening asymptomatic adults with the ankle brachial index could lead to some small degree of harm, including false-positive results and unnecessary work-ups."

As above, however, the USPSTF is clearly concerned about the true prevalence of disease as it has devised a draft research plan for screening for peripheral artery disease.

While I don't disagree with the findings of these two physicians that there is some risk in doing screening examinations, until we know more, to make a blanket statement that these types of examinations should be discouraged or not used is premature.

Here’s what we do know:

Stroke is the second leading cause of death worldwide, according to information from The University Hospital, the principal teaching hospital of the University Of Medicine and Dentistry of New Jersey. It is responsible for approximately 4.4 million deaths per year. Stroke is the third most common cause of death in the United States behind heart disease and cancer, and 700,000 people in the U.S. will die this year from stroke, approximately one every 45 seconds. Ten percent of stroke victims statistically recover almost completely. However 65 percent of stroke victims will require special care or die shortly after the stroke.

Approximately 500,000 of these strokes represent first attacks where the patient has had little or no warning prior to their stroke. And, while there are many in this category that are not related to carotid artery disease directly and are secondary to causes including hypertension, small vessel intracranial disease and amyloid angiopathy, for example, many of these are related to non-diagnosed silent atherosclerotic disease of the carotid artery.

With respect to screening for peripheral artery disease, according to the Society of Interventional Radiology: Peripheral artery disease affects an estimated 10 million people in the United States, or about 12 percent to 20 percent of Americans over age 65. And, in this article where Medicare claims status for more than 14,000 patients over 2 years was reviewed, it was found that costs and provider care were not alike. When patients are treated with minimally invasive techniques used by interventional radiologist, there is a potential cost savings to tax payers of approximately $230 million per year, as well as the additional benefit that patient outcomes are better.

Minimally invasive techniques used by interventional radiologists are more typically effective in earlier, less advanced disease states. The more advanced and more complicated the disease process, the more likely the patient will end up with surgery and/or amputation, increasing both the cost of initial care and the ongoing costs of rehab and additional surgery and intervention.

So, while I agree that screening examinations do have a downside, limiting, restricting or interfering with providing these screening examinations to patients should not occur.

As a final note, I would have to say that in the article as in a number of other current articles, attempts at frightening patients with unnecessary rhetoric is deplorable. If we are to truly bring patients to the table to help in making decisions about their care, we should present these patients with unbiased discussions of the specifics involved. Scare tactics and rhetoric have no place here.