Hospitals frequently fail to perform follow-up imaging after vascular surgery

Nearly half of patients failed to receive follow-up imaging within a year of vascular surgery, even if their hospitals participated in a national quality improvement registry, according to an analysis of Medicare beneficiaries.

The research encompassed 2,174 hospitals administering 3.2 million procedures for endovascular abdominal aortic aneurysm repair (EVAR), lower extremity bypass (LEB), peripheral vascular intervention (PVI), carotid endarterectomy (CEA) or carotid artery stenting (CAS). Clinical guidelines recommend postoperative surveillance imaging within the first year of these procedures to “monitor for procedural complications and ensure durable long-term outcomes,” the researchers wrote in a JAMA Surgery investigation published online Oct. 11.

However, over the study period, the following rates of surveillance imaging—via CT, duplex ultrasonography or ankle-brachial index—were observed at one year:

  • 55.4 percent for all vascular procedures throughout the study.
  • For EVAR, 50.5 percent in 2008-09 and 52.5 percent in 2012-13.
  • For LEB and PVI, 52.3 percent and 57.7 percent over the same timeframe.
  • For CEA and CAS, 74.6 percent and 77.7 percent.

Although there was a slight improvement over the study period, there was no significant difference in adherence in hospitals participating in the Vascular Quality Initiative (VQI) versus those who weren’t. VQI participation required hospitals to track patients for a year after their procedures and report results from follow-up imaging studies.

“Increasing the rates of surveillance imaging clearly represents an important opportunity for quality improvement, but using participation in surgical quality registries as a standalone strategy likely will not achieve this goal,” wrote Benjamin S. Brooke, MD, PhD, with the division of vascular surgery at the University of Utah School of Medicine, and colleagues. “To ensure that patients have durable outcomes after vascular procedures, we need to standardize protocols for follow-up imaging and extrapolate lessons learned in other successful surveillance programs such as cancer prevention.”

In addition, the authors wrote, “our data suggest that noncompliance may be associated with variation in procedure-specific surveillance protocols.”

In an accompanying editorial, Julie Ann Freischlag, MD, said patient focus groups could help doctors understand why compliance is so low for follow-up imaging.

“By asking the patients, we could better understand their expectations and knowledge of the need for postprocedure surveillance and its association with their long-term outcomes from their procedure,” she wrote. “We could ask the patients if the cost is too high or if the distance is too far, and if they know what the postprocedure plan is for return visits and imaging or if they fear returning to the physician’s office after the procedure.”

Freischlag also suggested using automated systems to remind patients about the need for postprocedure imaging.

“If we had almost 100% compliance with postprocedure surveillance imaging, we could then determine if surveillance is actually needed to prevent complications,” she wrote. “Owing to such low compliance, we really do not know the yield of finding abnormalities on the imaging scans, which could then be addressed to prevent complications.”