Nguyen et al.

Cardiovascular Ultrasound 2013, 11:42

http://www.cardiovascularultrasound.com/content/11/1/42
CARDIOVASCULAR
ULTRASOUND

RESEARCH Open Access

Novices may be trained to screen for abdominal

aortic aneurysms using ultrasound
Anh TV Nguyen, Geraldine B Hill, Matthew PT Versteeg, Ian A Thomson and Andre M van Rij*

Abstract
Background: Highly trained vascular sonographers make up a significant cost of abdominal aortic aneurysm (AAA)
ultrasound screening. However, they are over-trained for this very limited task. Others have reported that health
workers (e.g. emergency room staff and nurses) with far less training may be able to perform these scans. The
national AAA screening programme in the UK uses staff with limited training. Whether individuals without a health
professional qualification could be trained to perform the scan accurately to improve cost-effectiveness is not
known. We aimed to investigate whether a short, well-supervised course in ultrasonography could train novices
to detect AAA for screening purposes.
Methods: Three novices were trained by an experienced sonographer for 15 days to perform abdominal aortic
ultrasound examinations and detect AAA using a portable ultrasound system. The examination included four
anterior-posterior aortic measurements: a maximal diameter in the coronal plane and three diameters of the
suprarenal, mid and distal infrarenal aorta in the transverse plane. The novices independently scanned 215 subjects
following training; experienced sonographers repeated the measurements on the same subject in the same session.
Using Bland-Altman plots and CUSUM analysis, the novices’ and experienced sonographers’ accuracy and efficiency
measurements were compared. Factors influencing performance were recorded.
Results: The novices measured the maximal coronal aortic diameter accurately, to within 0.46-0.52 cm of the
true diameter; 85-97% of their coronal measurements were within 0.5 cm of the assessors; kappa statistic and
Bland-Altman plots show a high agreement with the assessor’s measurements. However, the novices’ measurements
of the three diameters in the transverse plane were outside clinically acceptable limits. Assuming a referral policy for a
second scan for scans recorded as ‘difficult’, only one novice missed a 3.13 cm aneurysm.
A CUSUM quality improvement analysis demonstrated substantial improvements in the scanning efficiency of the
novices with continued scanning experience.
Conclusion: This study showed that novices could be trained to screen for AAA over 15 days. However, the need for
continuing quality improvement is critical, especially in more technically demanding cases. Measuring the maximal
infrarenal diameter instead of specific segmental diameters may be more appropriate for AAA screening using novices.
Keywords: Abdominal aortic aneurysm, AAA, Screening, Novice, Ultrasound

Background in the first two years, which was much lower than the
Results from randomized controlled trials have suggested anticipated 4.5% to 7.7% from four large randomized trials
that screening for abdominal aortic aneurysm (AAA) is [3]. A possible reason for this is that AAA incidence may
beneficial and cost-effective [1,2]. Based on this evidence, be decreasing worldwide [4], which raises the question of
screening programmes for AAA have been implemented whether AAA screening will remain cost-effective in
in several countries. Recently, the United Kingdom AAA the future. This information is particularly important to
screening committee reported a detection rate of 1.7-1.8% countries that are considering implementing a national
screening programme for AAA, such as New Zealand.
Ultrasound detection of AAA is said to be a relatively
* Correspondence: [email protected]
Department of Surgical Sciences, Dunedin School of Medicine, University of simple and easy process [5] and so screening may
Otago, PO Box 56, Dunedin, New Zealand

© 2013 Nguyen et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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conceivably be performed by less extensively trained in Dunedin, operated as the assessors against whom the
staff who require only a short training period, making novices were compared. The most experienced member
the practice more cost-effective. On the other hand, of this group, with 16 years of experience in vascular
effective AAA detection relies on the accuracy of the ultrasonography, instructed the novices during the train-
ultrasound operator at measuring the aortic diameter, ing phase of the study.
particularly for small or borderline aneurysms. Less skilled
operators may not measure the aorta to a clinically Training
acceptable level of accuracy. It is therefore important The 15-day training course consisted of a theoretical
to determine what level of ultrasound skill and experience and a practical component. The theoretical component
is required for accurate AAA detection. included didactic teaching sessions on the principles and
The literature on this topic is currently limited. In techniques of ultrasonography, the anatomy of the abdom-
1998, Singh et al. [6] demonstrated that a radiologist inal aorta, the hemodynamic principles of arterial blood
and two cardiovascular nurses given two months of flow as well as AAA pathology and epidemiology. For
ultrasound training could subsequently detect AAA the practical component, the novices learned to use an
with accuracy. Two pilot studies concluded that less ultrasound machine, to acquire the static image of the
skilled people such as medical students and emergency abdominal aorta and to measure its diameter. A standard-
residents could screen for AAA after a short ultrasound ized protocol was implemented that involved measuring
course [7,8]. We postulated that people with even less four anterior-posterior aortic diameters: a maximal diam-
medical and imaging experience might be trained for eter in the coronal plane and a suprarenal, mid infrarenal
this task. This study aims to investigate whether three and distal infrarenal diameter in the transverse plane. The
novices, after 15 days of ultrasound training, could diameters were measured from the outer wall to the outer
reliably detect AAA. To achieve this, the accuracy and wall with electronic calipers on screen with the images
efficiency of aortic measurements by the novice trainees captured in systole. We defined an AAA as one with an
was compared with that of more experienced vascular infrarenal diameter of 3.0 cm or more. The novices
sonographers. practiced measuring the abdominal aortic diameter one-
to-one and in a group under supervision, and developed
Methods further experience during self-directed and peer-directed
Settings & patient recruitment practice. The trainer gave performance feedback during
This study was a double-blinded prospective longitudinal approximately 30 supervised sessions as well as feedback
study conducted over the 4-month period between based on the stored images collected. On average, each
November 2010 and February 2011. Participants aged novice had practiced performing 50 ultrasound exami-
50 years and above were recruited from the public and nations, which included patients with or without AAA.
from patients referred to the Otago Vascular Diagnostics
laboratory. The participants were instructed to avoid Equipment
smoking and “gassy” foods on the day of the scan to The novices used a portable laptop-based ultrasound
minimize bowel gas. Written, informed consent was system, Terason with the following features: 3.5 MHz
obtained having Ethical approval from the regional ethics curved array transducer, 25 cm penetration depth,
committee (Lower South Regional Ethics Committee). time-gain-compensation, B-mode, real-time imaging,
“cineloop” and depth control settings. These features
Novices are equivalent with the standard ultrasound system,
A group of three novices were recruited based on their Antares used by the experienced sonographers in a
previous lack of any imaging experience or training in clinical setting.
ultrasound. The group consisted of: Novice 1, a second
year (preclinical) medical student; Novice 2, a newly Screening and quality assessment
employed, inexperienced vascular technologist; and Once the 15-day training period was completed, the
Novice 3, a Physical Education graduate. All had ter- novices performed screening with no further feedback
tiary level health science education. Following the for the period of the study. The three novices measured
completion of the detailed initial study, a further two each participant’s aorta independently following the
subjects were recruited and assessed using similar standardized protocol and were compared to those
quality control measures. obtained independently by an assessor. Each novice and
assessor recorded the scanning duration, and the level
The assessors and trainer of difficulty obtaining each image on a scale of 1–4,
Five experienced vascular ultrasound technologists with 1 indicating the scan was not difficult, and 4 that
working in the Otago Vascular Diagnostics Laboratory, the scan was very difficult, with a sub-optimal image
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and the patient should be referred for formal screening 4 hours prior to their scans. One novice completed
at the Vascular Laboratory. The number of scans from only 182 examinations with absence due to sick leave.
which no image could be obtained was recorded.
After each ultrasound examination, participants com- Novice performance assessment
pleted a questionnaire to provide cardiovascular risk infor-
mation and demographics; fasting status, height, weight, a. Interobserver differences: The mean differences and
and waist and hip circumferences were also recorded. the variability and LOA for the measurements for
each novice at each aortic section are presented in
Statistical analysis Table 1. A high percentage of novice observations
The repeated measurements by the novices and the were within the CAD of ± 0.5 cm. The most
assessors were compared. The variability calculated as accurate measurements by the novices were the
1.96 times the standard deviation of the mean difference, distal infrarenal 94% (91-97%) measurements and
signified how much each novice’s measurements varied maximal coronal 92% (88-96%), as illustrated by
from an assessor’s. This variability was compared with a Figure 1A. In contrast, measurements taken in the
clinically acceptable difference (CAD) of 0.5 cm, described transverse plane of the mid infrarenal aortic section
by Jaakola et al. [9]. The 95% limits of agreement (LOA), exceeded the clinically acceptable range of variability
calculated by the sum of the mean difference and the as illustrated by Figure 1B. The poorest performance
variability, is the range within which 95% of the differences was in suprarenal measurements of the aorta, where
between the novices’ and the assessors’ measurements novices had an under-sizing bias of 0.5 cm, variability
lie. These are illustrated using the Bland-Altman plots outside of the acceptable limits, with only 62%
in which the differences between measurements of each (56 - 68%) of observations within the CAD, overall a
novice-assessor pair are plotted against the averages of poor performance as illustrated in Figure 1C.
those measurements. The proportion, measured in per- b. Strength of measurement agreement: Novices had
centages, of the novice’s and the assessors’ measurements very high levels of agreement with assessors in the
that were within 0.5 cm was calculated, as described by diagnosis of infrarenal AAA, with all novices having
Lederle et al. [10]. Kappa-statistics were used to determine a Kappa coefficient greater than 0.8. Novices had no
the interobserver agreement of aortic dilatation (≥ 3 cm) agreement with the assessors in the identification of
between each novice-assessor pair. localised suprarenal aortic dilatation.
To evaluate the novices’ scanning efficiency, the time c. Aneurysm Detection: The assessors identified ten
taken to complete the scans was retrospectively ana- infrarenal aneurysms, which ranged in size from 3.0
lysed using the Foresee cumulative summation (cusum) to 4.8 cm. Novice 1 missed three of these
calculator [11]. Two successful time outcomes were aneurysms, while Novice 2 and Novice 3 missed one
investigated: scan times within 5 minutes and scan each. All three novices missed a 3.5 cm AAA from
times within 10 minutes. The weights for success and the same patient. Novice 1 missed a second AAA
failure were calculated so that, if the process is set at a that was measured by an assessor at 4.3 cm. In both
predefined success rate, the cumulative score remains these cases all the novices graded the scans as a four
close to zero. Limit lines were calculated as described on the difficulty scale, which would have resulted in
by Gupta et al. [12] that when crossed, signal when a these patients being referred back to a more
performance has a higher or lower success rate than experienced technician and re-evaluated. The third
expected. AAA missed by Novice 1 was a small 3.1 cm eccentric
Continuous variables are presented as mean ± SD, aneurysm with a localized area of dilatation. The
unless specified otherwise, and were assessed using t- examination was rated “not difficult”, which was
Tests with Welsh correction. Variances were analysed inconsistent with the rating by the assessor and a
using the F-test and binary outcomes were tested peer novice (the third novice was not involved in
using Fisher’s exact test. measuring this aneurysm) and thus would not have
been referred back for re-evaluation.
Results
During the screening period novices and assessors Factors affecting performance
scanned 215 participants. There were 87 men and 128
women. The median age of men was 64 (range 50–86) a. Scanning Difficulties: Both assessors and novices
years and for women was 62 (range 50–105) years. The were able to capture and measure the aortic
average BMI was 28 ± 4.7 kg/m2; waist circumference diameter in 92-100% of images taken. Novices had
93.7 ± 13.4 cm; 30% were obese (BMI ≥ 30 kg/m2). less confidence in their infrarenal measures; rating
Regarding fasting status, 74% consumed foods within on average 18 scans (8.1%) as very difficult,
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Table 1 The mean difference and variability of novice measurements of the abdominal aorta
Aortic measurement Novice 1 Novice 2 Novice 3
Suprarenal
Mean difference −0.46 (−0.52, -0.41) −0.36 (−0.42, -0.31) −0.32 (−0.37, -0.27)
Variability 0.81 0.76 0.63
LOA −1.28, 0.35 −1.12, 0.40 −0.95, 0.31
n 196 193 161
Mid infrarenal
Mean difference −0.13 (−0.18, 0.07) −0.08 (−0.1, -0.02) −0.004 (−0.05, 0.04)
Variability 0.83 0.83 0.64
LOA −0.95, 0.70 −0.91, 0.75 −0.65, 0.64
n 214 212 179
Distal infrarenal
Mean difference −0.07 (−0.1, -0.03) −0.13 (−0.17, 0.09) 0.1 (0.06, 0.13)
Variability 0.49 0.61 0.49
LOA −0.56, 0.42 −0.74, 0.48 −0.39, 0.59
n 215 209 179
Max Coronal
Mean difference −0.07 (−0.1, -0.03) −0.05 (−0.09, -0.02) 0.05 (0.01, 0.08)
Variability 0.47 0.50 0.48
LOA −0.54, 0.40 −0.56, 0.45 −0.44, 0.53
n 209 194 167
Measurement of the abdominal aorta were taken in the transverse plane at suprarenal, mid infrarenal and distal infrarenal sections and the maximal aortic
measurement taken in the coronal plane. Mean difference (95% CI) (cm) of novice measurements from that of the assessors; variability of the mean difference;
limits of agreement (LOA); n, number of interobserver pairs. Scans from which no measurement could be attained were discarded from the analysis and thus the
numbers of inter-observer pairs are different in each aortic segment and each novice.

compared with assessors’ whom rated only one also observed in distal infrarenal measurements
infrarenal image (0.5%; P < .0001). Conversely, (0.40 ± 0.50 vs. 0.19 ± 0.17; P = .0251) and in the
assessors rated more suprarenal scans as very difficult maximal coronal measurements (0.29 ± 0.24 vs.
(8.4%) than the novice trainees (4.5%). There were no 0.16 ± 0.15; P = .0067).
significant differences in measurement performance
observed between scans that were rated as 1 to 3 on Documenting progression in learning
the difficulty scale.
b. Body Habitus: For both assessors and novices a. Cusum performance: During the screening period
patient habitus was a significant factor the assessors completed 95% (205/216) of the scans
contributing to scanning difficulty, as obese patients within 5 minutes. Novice trainees achieved this in
(BMI > 30 kg/m2) were more likely to have at least only 7.4% (48/653) of scans, and therefore this was
one image in their scan rated as a 4 on the difficulty not a useful learning benchmark. Using the
scale, compared with their normal sized 10-minute criterion with an expected 90% success
counterparts (41.8 vs. 17.6%; P = .0003). However, rate as the benchmark, an improvement in the
obesity and central adiposity did not affect the novice’s performance was seen over the course of
overall measurement accuracy of the novices. the scanning period. Initially all novice trainees failed
c. Aortic size: The measures of variation between each of to achieve an acceptable success rate, but after scan
the novices and the assessors were generally greater 110 a plateau on the learning curve of all trainees
for aortas ≥ 2.5 cm than those smaller. At the mid was observed. Thereafter one trainee immediately
infrarenal level, the absolute mean difference of novice and one at scan 180 showed performances that
measurements was significantly greater in aortae paralleled the assessors’ at this criteria, but the third
measured 2.5 cm or greater (0.68 ± 0.48) compared had not yet reached this even by scan 210 (Figure 2).
with those taken in aortae with diameters less b. Learning progression: After 110 scans the variability
than 2.5 cm (0.22 ± 0.26; P = .001), this effect was of novice measurements from the mid-infrarenal
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Figure 1 Bland-Altman plots. Illustrating variations in performance.

Bland-Altman graphs plot the inter-observer differences of the
novice-assessors (y-axis) against the averages of those measurements.
The dotted lines demarcate the limits of agreement (LOA), which
should ideally lie within the clinically acceptable difference (CAD) of
0.5 cm. A demonstrates an acceptable performance by Novice 3 when
measuring the maximal coronal diameter, with no measurement bias
and the LOA within the CAD. B shows unacceptably high variability in
Novice 1 measurements from mid-infrarenal aortic section with outliers
in both normal and aneurysmal aorta. C shows a large under-sizing
bias of 0.5 cm by Novice 1 when measuring the suprarenal segment of
aortae, in addition the variability of measurement exceeded the CAD.

section of the aorta was lower than the first half of

the screening period (−0.16 ± 0.34 vs. 0.01 ± 0.44;
P < .0001). Little change in variability was observed
with measurements in the more consistently measured
coronal plane and distal transverse diameters. In
the latter half of the screening period novices also
had more confidence in their scanning ability,
rating fewer images as 3 or 4 on the difficulty
scale (29.4% vs. 37.5%; P = .03).

The two novices recruited subsequent to the initial

study and assessed with the same quality control tools
described yielded comparable outcomes on the Bland-

Figure 2 Cusum plots demonstrating the progression in

scanning efficiency for each novice over the study period. The
mean and SD were calculated from a sample of 220 scans with a
90% success rate, using 10,000 iterations in the bootstrapping
procedure. Limit lines (dotted grey lines) demarcate when the
success rate becomes higher or lower than would be expected if
due to chance with 97.5% certainty. The criterion for a success was
any scan completed within 10 min and is charted as an increase of
0.21 on the chart. Failure, results in a decrease on the plot of −1.79.
Assessors have a higher success rate than 90% and cross the upper
boundary limits at scans 56, 118, 171; Novice scanners have lower
success rate than expected: Novice 1 crosses lower limits at scans
22, 39, 59, 83, 97,104, 173; Novice 2 crosses lower limits at scans 30,
44, 58, 90, 103; Novice 3 crosses lower limits at scan 81. After scan
110 a plateau in performance occurs in the novices performances.
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Altman plots. Cusum was utilized in a similar manner to Whatever measurement used, a continuing quality
track learning progression. improvement programme should be required which
monitors performance as well as the inclusion of safe
Discussion guards in the screening protocol to reduce near misses.
The use of individuals with limited training as AAA With this in mind, we looked at factors influencing
screening sonographers remains a contentious issue. Whilst performance. These included technical difficulties related
utilizing novices could significantly reduce the cost of to the subject’s habitus and clinical state in particular
screening programmes, the accuracy and reliability of those who were obese. Similarly the study by Hoffman
abdominal aortic measurements is imperative. The novices et al. [20] reported that visualization of the abdominal
in this study had a very high agreement with the skilled aorta largely depended on the sonographer’s experience,
sonographers in the diagnosis of infrarenal AAA, and bowel gas and body mass index. However, despite the level
if a screening policy to refer very difficult scans for of difficulty reported, the accuracy of aortic measurements
reevaluation in a vascular laboratory was applied, then all by the novices were independent of obesity and central
of the aneurysms would have been detected, excluding adiposity.
one aneurysm by a single novice. Other difficulties include the eccentric aneurysm and
Studies comparing CT and ultrasound measurements tortuous aortas, as well as the misidentification of other
of the aorta commonly deem differences of less than structures (e.g. the inferior vena cava, the superior mes-
0.5 cm between the equivalent methods clinically accept- enteric artery and the gall bladder) from the aorta and
able [6,9,10,13,14]. This limit has also been adopted when the accurate selection of the boundaries of the aortas
evaluating the performance of newly trained sonographers. [9,21]. It is suggested that these factors should all be
Five internal medicine doctors were able to measure the specifically addressed in a training programme and in
maximal aortic diameter within 0.5 cm of fully trained continuing quality improvement strategies.
sonographers after 9.6 hours of training [7]. Kuhn and Other safe guards to avoid missing aneurysms in these
colleagues reported that Emergency Physicians could be circumstances are the inclusion of protocols for referral
trained to identify AAA after 3 days of ultrasound training. of difficult subjects for a second assessment by an experi-
However, the measurement variability and reliability of enced sonographer. The decision to refer is dependent on
the aortic measurements was not reported [15]. the confidence of the screener to make the call whether
When imaging the maximal coronal aortic diameter, the an adequate study has or has not been performed. The
novice’s measurements were within 0.5 cm 85-97% of the novices in this study had a higher rate of referral for
time, with a variability ranging between 0.47-0.50 cm. infrarenal scans than that of the assessors, and had less
Measurements on the transverse plane were more variable confidence in their measurements, however the novices
than those taken from the coronal plane. These require also demonstrated a false confidence in their supra-renal
more technically demanding steps such as the identifi- measures, where they performed the worst. Monitoring
cation of the superior mesenteric and the renal arteries, the perceived difficulty scores for each scan as well as
a process which could generate greater variability in the referral rate for second assessments relative to an
the site of measurement. This was particularly evident experienced sonographer may be good quality measures.
in the suprarenal and mid-infrarenal aortic measures. Another proposal is to rescreen all 2.5-2.9 cm aortas by
As illustrated by the Bland-Altman plots, novices had experienced sonographers [22]. This suggestion is com-
unacceptably high variability in these two sections, and patible with Jaakola et al. [9] and our own result showing
showed a significant under sizing bias in the suprarenal that measurements of aortas ≥ 2.5 cm were more variable
aortic section. This suggests that for a screening prog- than those smaller, however this approach compromises
ramme employing novice trainees, rather than measuring the cost-effectiveness of screening.
the anterior-posterior diameter at discrete points along Another important factor in performance is the innate
the aorta, a maximum measurement should be taken learning ability and individual systematic measurement
from a view that encompasses a continuous section of bias of the individual screener. This study was able to
the aorta, such as a longitudinal or coronal measurement identify some of these characteristics using the measures
to the bifurcation point; a finding that is consistent with of variability, and Bland Altman plots as well as the
recommendations for AAA screeners in previous trials perceptions of difficulty, visibility and the duration of
[16-19]. Additional training and feedback might have the procedure. These measures could provide the basis
improved the quality of the transverse measurements for performance monitoring for individual feedback and
as the ultrasound operators of the Singh et al. study remedial activities. They could be used for accreditation
[6] had substantially more training and practice and of training prior to independent screening as well as for
achieved acceptable accuracy of all the transverse continued practice audit to standardize the competence
aortic diameters. levels of novice-trained screeners.
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The design of this study with one-on-one evaluation in Received: 24 July 2013 Accepted: 13 November 2013
over 200 scans might not be pragmatic for a training Published: 22 November 2013

programme. Other approaches have been to evaluate qual-

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doi:10.1186/1476-7120-11-42
Cite this article as: Nguyen et al.: Novices may be trained to screen for
abdominal aortic aneurysms using ultrasound. Cardiovascular Ultrasound
2013 11:42.

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