Choosing wisely for syncope: low-value carotid ultrasound use

The United States spends more than $750 billion annually on tests and procedures that do not benefit patients. Although there is no physiological indication for carotid ultrasound in "simple" syncope in the absence of focal neurological signs or symptoms suggestive of stroke, there is concern that this practice remains common for routine syncope workups.

We used a 5% random-sample Medicare claims database to evaluate large-scale national trends in utilization of low-value carotid ultrasound imaging for simple syncope. We found that 16.5% of all Medicare beneficiaries with simple syncope underwent carotid imaging and 6.5% of all carotid ultrasounds ordered in 2009 were for this low-value indication. These findings were complemented by a manual chart review of 313 patients at a large academic medical center who underwent carotid ultrasound for simple syncope over a 5-year period. For the 48 (15.4%) of 313 patients with stenosis ≥50%, carotid ultrasound did not yield a causal diagnosis. Only 2% of the 313 patients imaged experienced a change in medications after a positive study, and <1% of patients underwent a carotid revascularization procedure.

These data suggest that carotid ultrasound for patients with uncomplicated syncope are still commonly ordered and may be an easy target for institutions striving to curtail low-value care.