Endovascular thrombectomy decision-making: Practice area and physician experience among top factors influencing choice to treat

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Mayank Goyal

A survey investigating the factors associated with the decision-making for endovascular thrombectomy (EVT) procedures found that such decisions differed significantly between regions and specialities depending on their local resources, but not under assumed ideal conditions. At the Society of NeuroInterventional Surgery’s (SNIS) annual meeting (22–25 July, Miami, USA), Mayank Goyal from the University of Calgary, Canada, lead author of the study, said that the most important factors influencing EVT decisions are the National Institutes of Stroke Scale (NIHSS) scores (34.9%), the level of evidence (30.2%), ASPECTS or ischaemic core volume (22.4%), patients age (21.6%) and clinicians’ experience in EVT procedures (19.3%).

“Physicians of different specialties and practicing in different geographic regions make decisions based on different external variables,” said Goyal, adding that, “While it is promising to see acceptance of EVT as the standard of care for patients with acute ischaemic stroke, it is clear that more work needs to be done to standardise decision-making for the benefit of all patients.”

In order to determine patient, practitioner and health system factors associated with real-life EVT decision-making, Goyal and colleagues took 22 case-scenarios from 38 countries to form the contents of the survey. Then, each survey included 10 scenarios at random, each questioning, “How would you treat it, and how do you think it should be treated?”.

“If you think about it, many factors including patient demographics, the clinical presentation, as well as physician factors and local access factors all come into play collectively to decide whether the patient gets treated or not,” surmised Goyal.

Now speaking to NeuroNews, Goyal discusses the results.

Did any of the results surprise you?

Overall, most of the results matched our expectations. We were pleasantly surprised to see most physicians decided to offer endovascular treatment regardless of patient age, co-morbidities, etc., and even in those case-scenarios for which no clear guideline recommendations for EVT exist.

Did you find any gender disparities in EVT decision-making?

We did not find any significant differences in treatment decision-making between female and male physicians. However, the resources gap was higher for females compared to males (8% vs 2%), in other words: 8% of female physicians wanted to perform EVT but could not due to external limitations, while the number for male physicians was lower (2%). We assume that this is because female physicians were mostly neurologists, and as opposed to neurosurgeons/interventional neuroradiologists, they often work in smaller hospitals with limited access to endovascular treatment. However, we can only speculate about the reasons for this observation, and it might well be a coincidence, since it did not reach statistical significance.

How does decision-making vary geographically? Were there any unexpected results pertaining to this?

We found vast variations in endovascular treatment decision-making among different regions of the world. As expected, the resources gap in some countries in South America and South Asia for instance, was larger. However, there were a few unexpected findings, too: the United Kingdom, for instance, despite being a relatively wealthy, “first-world country” had a dramatic resources gap of 33%, that means UK physicians cannot perform endovascular treatment in on out of three patients due to external limitations, although they would want to.

Is there a knowledge gap? What can we do in the future to close this?

We indeed found a small knowledge gap in our study: under ideal conditions (i.e. when assuming there are no external restraints), the decision rate for case-scenarios with level 1A evidence for EVT should ideally be 100%, since the guidelines clearly recommend EVT in these cases. But the decision rate we observed was lower (90.6%). This means physicians decided not to offer EVT in almost one out of 10 cases in which it was clearly indicated. This is what we called “knowledge gap” in our study, but there are several explanations: one is that physicians are not aware of the guidelines (“real” knowledge gap), but it might as well be that they know the guidelines but do not personally agree with them and deliberately decided not to follow them. We think that it is important to better understand the reasons of this presumed knowledge gap in order to increase guideline adherence and endovascular treatment rates further. Newsletters and regular updates from professional societies and refresher sessions at meetings can help to improve guideline awareness and close the knowledge gap.

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