Naomi M. Hamburg, MD, MS, FASE

Vascular ultrasound comprises an integral component of the care of patients with a diverse variety of patients with vascular diseases. With worldwide population aging and increasing burden of metabolic diseases, vascular diseases are increasingly common and contribute to significant disability. Ultrasound is a rapid, low-risk means of diagnosing atherosclerotic disease that can inform therapies to reduce the risk of stroke and amputations. The vascular lab also contributes trauma management. This was clear at Boston University Medical Center as we cared for people injured at the Boston Marathon tragedy. Maximizing value in vascular ultrasound requires both well-trained practitioners and reliable vascular laboratories.

The COCATS 4 Task Force 9: Training in Vascular Medicine document (available at http://content.onlinejacc.org/article.aspx?articleid=2199473 ) was published in March 2015. I participated as a member of the task force that was chaired by Dr. Mark Creager. The overall focus of COCATS 4 is on developing core competencies across cardiovascular training with an emphasis on outcomes assessment. A few changes in the vascular training section are worth highlighting. First, the description of training in noninvasive vascular medicine practice was separated from the training required to become an interventional specialist performing peripheral procedures. Similar to other areas in cardiovascular medicine, Level I milestones should be achieved by all cardiovascular trainees during the first 24 months of fellowship. Level II milestones require additional elective time over the 36 months of training and Level III training is pursued in an additional year of training. The document focuses largely on the training in vascular medicine for both Level I and II. Cardiovascular fellows are expected to achieve a broad knowledge of the evaluation and management of common vascular diseases.

A major component of vascular medicine training instruction is the indications and interpretation of vascular ultrasound and physiologic testing in a noninvasive laboratory accredited by the IAC Vascular Testing Division. Milestones for all cardiovascular medicine trainees (Level I) include knowledge of the indications for duplex ultrasound of peripheral veins and carotid arteries as well as physiological testing of the peripheral arteries. More advanced training (Level II) competencies include the skill to interpret noninvasive arterial testing as well as duplex ultrasound testing of arteries and veins. The detailed description of the Noninvasive Vascular Laboratory portion recommends that all advanced trainees (Levels II and III) have supervised interpretation experience of at least 500 studies across the spectrum of vascular testing areas. The training curriculum should also include exposure to the quality assurance process in the vascular laboratory. It is expected that the ARDMS Physicians’ Vascular Interpretation Examination (RPVI) ( www.ardms.org ) be completed as part of Levels II and III training. Thus, cardiovascular trainees have the opportunity to become well-versed in noninvasive vascular testing as part of the 36-month fellowship program and to meet the requirements to become certified in vascular testing through the RPVI examination. The clear outline of the knowledge and skills and pathway to certification in vascular interpretation will facilitate growth in the number of cardiovascular fellows who become qualified vascular ultrasound practitioners.

The ASE is one of 12 sponsoring organizations of the IAC Vascular Testing Division, and I have served as one of the two ASE representatives to the Board of Directors for the past three years. The IAC Vascular Testing Standards outline the underlying processes required for accreditation. The Board of Directors reviews and revises the Standards to ensure that they represent the best practices to guide high quality vascular imaging. There are a few modifications in the standards (published this month) that will become effective in January/February 2016. The changes to the Quality Improvement (QI) Program are the most notable and represent an intensive review across the IAC divisions. The emphasis of the QI program is on five elements: test appropriateness, technical quality and safety of the imaging, interpretative quality review, report completeness and timeliness, and case review. Test appropriateness involves categorizing into three groups: appropriate/usually appropriate, may be appropriate, rarely appropriate/usually not appropriate. Technical quality review includes image quality, completeness, and adherence to protocol. Interpretive quality involves assuring the accuracy of interpretation. Reporting involves evaluating the reporting process as required in the Standards.

Importantly, the process of case review to evaluate testing accuracy has evolved. The requirement to keep a correlation log that demonstrates accuracy for each area of testing has been removed. In place, the case review process involves review with “any appropriate imaging modality, surgical findings, clinical outcomes or other comparison of a minimum of four cases annually with at least two cases per relevant testing area” ( www.intersocietal.org/vascular/main/vascular_standards.htm ). Documentation of the QI process involves the data from the five QI measures, minutes from QI meetings, and a participant list in meetings (may include remote participation and/or review of minutes). The overall QI process is designed to encourage case review and continuing engagement in QI by all participants in the vascular laboratory. Also, the elements of the QI process are harmonized across the IAC divisions including IAC Echocardiography.

Noninvasive vascular imaging including ultrasound remains a critical component of comprehensive vascular care. The updated cardiovascular training document and the QI process for IAC accreditation will accelerate access to high quality and value vascular ultrasound.

Dr. Naomi Hamburg, MS, FASE practices Cardiology and Vascular Medicine at Boston Medical Center and is an Associate Professor at Boston University School of Medicine. She serves as an ASE representative to the IAC Vascular Testing Board of Directors.