|SCAN OR SCAM|
Do quick ultrasounds give reliable answers about stroke risk?
Robert Hayes is just like many of your patients, and he lives a pretty good life. The 77-year-old retired executive feels healthy and plays golf twice a week, so the last thing he wants is to have a stroke. That’s why Hayes paid $40 for a four-minute ultrasound scan of his carotid arteries at a “stroke screening event” near San Diego.He was one of 17,000 people in the San Diego area alone to pay for the quick-scan ultrasound over the past 12 months. The test is now offered by dozens of franchise outlets nationwide. Nurses are increasingly likely to get questions from patients about the scans or to see patients who arrive at primary care offices with results in hand. Companies like Prevention Plus, Medical Screening, and Longevity Inc. advertise their stroke screenings in newspapers and on television, then bring their mobile ultrasound machines to places where older people often gather—senior centers, churches, synagogues, and mobile home parks.Experts disagree on the role of the quick-scan ultrasounds. Proponents say they are a valuable, affordable, mass-screening tool that saves lives and money. Opponents say they are unnecessary and often inaccurate and can end up raising a person’s total healthcare bill in the long run.Community service“About 95 percent [of customers] are fine, but the others are walking time bombs,” said Jeff Quist, president and owner of Prevention Plus, formerly known as Life Line Screening, in Carlsbad, one of 26 national offices of the St. Petersburg, Fla.-based company. “Based on the results of the scans, we prevented 300 to 400 strokes last year.””We educate people about stroke and we bring the equipment to them,” said Phil Kessler, owner of Medical Screening in Encinitas. “We do the test for a reasonable price. It’s our way of giving back to the community.”Critics think otherwiseNot everyone sees the quick-scan business in such an altruistic light. One of the most vocal critics is certified vascular nurse and registered vascular technologist Franklin West, RN, director of clinical research and development at Pacific Vascular Inc., a company with 14 vascular labs in the Seattle area. Earlier this year, West consulted on an ABC investigation of vascular labs and stroke-screening companies. (A show on the latter has not aired.) He and a patient known to have significant vascular disease attended a screening run by Prevention Plus in south Florida.”I’m a healthy 40-year-old with no known risk factors, and they said I should have the carotid ultrasound,” West said. “They’ll test anything that’s breathing.”Ultrasound checklistPatients should ask these questions before having an ultrasound:>Why am I having this test? Do I have symptoms?>Does the technician have the proper credentials and experience to do the test?>Is the lab accredited?>Can results be sent directly to my physician?The carotid scan (and abdominal aortic scan and ankle-brachial index) was administered in a hurried, sloppy fashion by unregistered technicians, according to West. “They missed everything with the severely diseased patient. These companies have no quality control, and there is no evidence that these screenings are of any benefit.”Nobody’s perfectThe charge that many quick-scan ultrasounds are inaccurate “is just an opinion,” said Geoffrey Risley, MD, a San Diego vascular surgeon who said he read about 20,000 carotid and abdominal aorta scans for Prevention Plus in Carlsbad last year.”Nothing is 100 percent,” he said. “Even with the complete test, you’ll miss 5 percent. [The quick scan] looks at the most common place in the carotid artery where blockages occur, and we see abnormal findings in about 6 to 15 percent of the people over 65. We’re trying to check the accuracy rates, but unfortunately, I don’t do all the follow-up ultrasounds.”Prevention Plus states in its brochures that “certified or registry-eligible sonographers” administer the tests. Quist says its tests are performed only by registered vascular technicians. When asked who should have the scans, Quist said, “Of course, older people are at greater risk, but anyone can have a stroke.” West counters that strokes due to blockages are almost unheard of in younger patients.Question of interpretationNo matter where ultrasound scans are administered, the quality depends on the technician and the interpreter, according to Sandra Katanick, executive director of the Intersocietal Commission for the Accreditation of Vascular Laboratories in Columbia, Md. The skills they bring are important because the quality of the scans themselves can vary.”If the patient is a thin, healthy person, you can get a good image on the cheapest ultrasound machine,” she said. “But if you’re overweight, a clear image is less likely on the low-end machines.” Interpretation is important because “plaque has the same ultrasound characteristics as the vessel walls. This makes it easy to go right by the plaque in a fast exam.”Overall valueEven if the tests were accurate, “of what value are they?” asked Patrick Lyden, MD, chief of neurology at UCSD Medical Center. “Is anyone going to do surgery on a patient with a blockage and no other symptoms? The chances are almost nil because blockage is only one risk factor.”And regardless of accuracy, primary care physicians are obliged to order the full ultrasound if there is any doubt, Lyden said. As a result, “these companies are imposing an impossibly excessive burden on the healthcare system.”Depending on a carotid scan alone as a measure of health is dangerous, according to the National Stroke Association. “It can give you a false sense of security because blocked carotid arteries are only one risk factor for stroke,” said spokesperson Jennifer Reid. “Other causes are atrial fibrillation, hypertension, embolus, and hemorrhage.”Appropriate roleAt least one expert believes quick-scan screening has a place in stroke prevention if coupled with a brief ECG and blood pressure check. “Stroke-screening technique is evolving, and we’re trying to find the best way,” said George Lavenson, MD, a Visalia vascular surgeon whose studies on stroke screening appear in the November issue of Cardiovascular Surgery. “The companies aren’t perfect, but at least they are screening for the biggest cause of stroke.”Lavenson believes hospitals should do the quick scans for free. “It can be a win-win situation for everyone. Hospitals will get the business for the follow-up ultrasounds for those who need them, and we’ll prevent strokes and save a lot of money.”