IR faces ‰ÛÏring of fire‰Û: Call for improved clinical judgement and evidence

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Jon Moss, Glasgow, UK, delivered the CIRSE 2011 Andreas Gruentzig lecture. He advocated greater clinical judgement and warned that there was a “ring of fire” in interventional radiology with several procedures being carried out without strong evidence backing them.

 

Moss’s talk, titled “Evidence based interventional radiology—not how but if and when”, focused on the need for greater clinical judgement from interventional radiologists and more evidence behind several of its procedures. “People do not necessarily like to hear bad news nowadays […but] It is time for change,” he urged delegates, “not ‘if’ and ‘when’, but ‘now’.”

 

Moss told delegates that it would be awfully easy to talk about the good things in interventional radiology—its strengths, or the pioneers and how their spirit and persistence advanced the discipline. “But I am going to talk about what is wrong with interventional radiology and finish on a positive note about how we can fix what is wrong,” he said.

 

“As a more mature specialty we must move on from talking about how to do a procedure to talking about when we should do it, and if we should do it at all. I do not think we are terribly good at, as interventional radiologists, clinical judgement. A lot of clinical judgement is based on evidence and there we have another problem, because we are weak, but getting better, at clinical evidence,” Moss said.

 

Moss played heavily on the importance of running an interventional radiology clinic as a way of exercising clinical judgement. Clinics are seen as the “front door” to a specialty, and he argued that it is vital that interventional radiologists become more involved in clinic work. A recent survey of practice in the UK showed that 57% of consultants offer clinic access. Although encouraging, it clearly leaves room for improvement, he noted.

 

A small cut does not always equal a small risk

 

Moss told delegates that “some of the problems we have with clinical judgement, we have inherited from diagnostic radiology. In most countries, we simply do the procedure.” Interventional radiology is often a rescue service and too often interventional radiologists simply say ‘yes’ to a request, even if the prognosis is poor. However, the results of interventional radiology in Scotland are being measured along the same lines as surgery (using the Scottish Audit of Surgical Mortality mechanism). Moss emphasised that interventional radiologists needed to know when to say ‘yes’ and when to say ‘no’ to performing a procedure.

 

He used the example of percutaneous biliary drainage, which has a high mortality rate to illustrate the point. “The British Society of Interventional Radiology ran a registry a few years ago which found that the procedure carried a 30-day mortality of 30%. This is very high, much higher than cardiac surgery and when you perform a biliary drainage out of hours in the UK, that mortality doubles to 60%. This suggests that we need to improve our clinical judgement and have better patient selection,” said Moss.

 

“I put it to you that we should not be doing things to patients because we make a small cut. A small cut does not necessarily correlate with a small risk, even though a referring doctor might think that that is the case,” he noted.

 

A ring of fire with regard to evidence


Moss also stated that there was a “ring of fire” in interventional radiology comprising certain procedures behind which the evidence was weak, controversial or lacking.

 

The procedures constituting the ring include drug-eluting stents, radiofrequency ablation, vertebroplasty, inferior vena cava filters, renal denervation, chronic cerebrospinal venous insufficiency, renal stenting, transarterial chemoembolization, superficial femoral artery stents and more, he noted.

 

“You might not like it, but this ring encompasses most of what we do. I do not want to detract from the good and excellent work that various groups have done and are continuing to do in advancing our understanding in these areas, particularly in carotid stenting, EVAR and more recently, interventions in the superficial femoral artery with metallic stents and drug-eluting stents. But the fact remains that for all of these procedures the evidence is either not there, or it is weak and needs to be beefed up a little,” he said.

 

He also touched on some recent positive aspects in interventional radiology which has attained subspecialty status in Europe, and in the UK where it has a curriculum with more clinical medicine. Qualifications such as the European Board of Interventional Radiology (EBIR) were also hailed as a positive development. He also stated that in the UK, interventional radiology was being viewed as one of five subspecialties that have been recognised with a need for increased training numbers to expand the specialty […] We used to be at the back, we are slowly creeping forward and one day not far off, we will be doing a lot more leading than following,” he said.

 

What needs to be done?

 

  •  Make the time to do the research
  •  Set up clinic time
  •  Try and build up a robust out of hours interventional radiology practice
  •  Sit on the committees and speak for the specialty. Do not let other specialties speak for you—those days are over, said Moss

 

Listen to the entire 2011 Andreas Gruentzig lecture on www.esir.org. Moss also delivered the Wattie Fletcher Lecture on the topic “The Missing Link–Evidence-based Practice” at the British Society of Interventional Radiology annual meeting in Glasgow, UK, on 3 November.

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