Douglas Wooster

Fishing for BASS: Surveying Primary Physicians in the Barriers to Aortic Screening Study

Introduction In response to published guidelines for abdominal aortic aneurysm (AAA) screening, primary care physicians were surveyed to determine attitudes and identify barriers to screening. Methods Six hundred standardized, structured surveys were distributed to all primary care practitioners in a defined geographic area. Participation was voluntary, and results were anonymous. Results A total of 10.7% of surveys were returned. All questions were answered by >93% of respondents. A total of 71.9% of respondents were general practitioners; 94.4% worked in a community setting. 60.9% saw >11 male patients per week who were older than 65 years of age. Responses indicated support for identifying asymptomatic AAAs; only 4.7% thought their patients were too sick to undergo repair, 0% felt their patients would be unwilling to undergo repair, and 0% felt the risk of rupture was too small to justify repair. Access to vascular surgical services was available to more than 75% in the hospital closest to them, and to 100% in the city in which they practice. A total of 42.2% were aware of recommendations regarding AAA screening, and 65.6% of physicians routinely screened eligible patients for AAAs. Screening for other diseases was more frequent. Respondents routinely screened their patients for breast cancer (79.1%), prostate cancer (80.5%), colon cancer (80.9%), and hypertension (83.7%); 42.9% routinely screened for peripheral artery disease. Conclusion Screening for AAAs lags significantly behind other major screening programs. Although primary practitioners are routinely exposed to the target population, a minority of patients are screened. Neither access to a vascular surgeon nor knowledge about the importance of AAAs appears to be limiting factors. Despite recent publicity, almost 60% of primary care physicians remain unaware of screening guidelines for AAAs. Of those who were aware of guidelines, only one third follow them. Further research and education is required to increase the efficacy of screening.

Pattern Analysis of Lower Extremity Venous Thrombosis: Implications for Point of Care Ultrasound (POCUS) Protocols:

Introduction Emergency department point-of-care ultrasound (POCUS) can identify lower extremity venous thrombosis (LEVT) with a published accuracy is 85–90%. The aim of this study was to compare the patterns of LEVT with protocol results and determine the clinical impact of the study results. Methods Patterns of superficial venous thrombosis(SVT) and deep venous thrombosis (DVT) were collated from positive venous duplex ultrasound (VDU) studies. Each pattern was mapped to the potential findings by the described POCUS protocols. Analysis of the literature was used to identify the potential clinical impact of the findings and the functional efficacy of each strategy and a numerical result was developed. Results One hundred six studies were positive for DVT (42), SVT (44), or both (20) on VDU. Patterns for DVT (single or multiple levels and unilateral or bilateral) and SVT (great saphenous vein above and/or below knee or small saphenous vein in single, multiple or bilateral and juxta-junctional) were noted. The patterns covered by the “two-area” protocol showed DVT = 80% and SVT = 38%, and by “three-point compression” DVT = 74% and SVT = 0%. Particular areas not covered included proximal disease (iliac and vena cava) and calf DVT and SVT in all areas except juxta-junctional. The potential impact for DVT is high, whereas for SVT it is moderate to low. The functional efficacy of the “two-area” protocol (5.9) exceeds the “three-point compression” strategy (3.7) but falls short of the “gold standard” VDU (10). Conclusion Pattern analysis of venous thrombosis identifies weakness in POCUS strategies; the clinical implications allow for an assignment of the functional efficacy of each study. Knowledge of these findings should inform emergency room POCUS strategies.

A Structured Audit Tool of Vascular Ultrasound Interpretation Reports: A Quality Initiative

Quality initiatives in clinical practice are important in improving patient care, providing cost-effective management, and enhancing communication and collaboration among health care professionals. Such initiatives can be based on available practice and protocol guidelines, credentialing processes, and accreditation programs and standards. The application of defined study protocols by well-trained and credentialed personnel, using appropriate ultrasound equipment and reported in a thorough and consistent fashion, should result in high-quality, clinically useful studies.1 The interpretation report of an imaging facility is recognized as the “product” of the diagnostic test. It is important that it be structured to serve as both a documented output from the test and a communication tool to the referring and other physicians. The interpretation report relies on a high-quality, complete technical study, appropriate interpretation guidelines, and a qualified reporting physician. Various societies and agencies have developed and published guidelines that establish the standards for interpretation reports of diagnostic testing. These guidelines can be used as the basis for quality initiatives.1,2 The performance of a vascular diagnostic facility can be defined by the quality of the output as measured by the test interpretation report. Assuming that adequate equipment is used, technical protocols are appropriate and skilled technologists are performing the tests, the interpretation report may not reflect high-quality output. Even with an awareness of available standards, the day-to-day performance of individual interpreting practitioner may not reflect the recommendations for high quality studies. This shortcoming may not be recognized or clearly defined if recognized. Audit tools are helpful to objectively define performance gaps in clinical practice; these gaps may not be recognized otherwise. Self-assessment through reflection and addressing such gaps is intuitive in professional practice and can lead to appropriate professional development strategies for improvement.3 If an objective scoring system is applied to the audit, repeated audits can demonstrate and quantitate quality improvement. The aims of this study were to develop a structured audit tool of vascular ultrasound interpretation reports for use in self-assessment, quality assurance and objective scoring in clinical vascular ultrasound practice.