Leading interventional radiology societies call for expanded stroke training

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In a joint, global position statement, the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiology Society of Europe (CIRSE) and the Interventional Radiology Society of Australasia (IRSA) have committed to providing necessary stroke training to interventional radiologists in order to alleviate the shortage of physicians trained in endovascular stroke therapies.

THE ABILITY FOR patients to access thrombectomy care remains stymied by geography and a shortage of interventional physicians, despite the American Heart Association’s and multiple international stroke organisations’ recommendations that endovascular thrombectomy (EVT or clot removal) be the standard of care for patients suffering acute ischaemic stroke caused by blocked arteries.

“The shortage of physicians and comprehensive stroke centres providing EVT has been confirmed by the stroke neurology community, who recommend that patients be treated locally rather than having long transfer delays,” the joint statement said.

“Appropriately trained interventional radiologists can evaluate stroke patients and provide emergent EVT with good outcomes; especially where neurointerventional physicians are not available.”

Interventional radiologists can also help provide 24/7 care in partnership with neurointerventional physicians where they are available, the statement said.

Endovascular thrombectomy is proven to save lives and improve outcomes for patients suffering acute ischaemic strokes. Patients who undergo these clot-removing treatments not only survive in greater numbers, but also have fewer resulting disabilities and are able to recover functions faster than best medical therapy.

“Reversing symptoms from these strokes requires rapid and safe removal of the occluding thrombus,” the societies said in the statement. Allowing interventional radiologists to join their neurology, neurointerventional and neurosurgeon colleagues on care teams and allowing them to be part of certified stroke centres will greatly increase access to this critical treatment, they said.

SIR is already revising its current stroke training guidelines to support expanded patient access to interventional stroke treatment. The training pathway will reinforce Joint Commission and American Heart Association requirements for physicians operating in thrombectomy-capable stroke centres and comprehensive stroke centres. In September, the Joint Commission and American Heart Association announced they would hold a dialogue with provider organisations to discuss requirements as the organisations work to update certification criteria for both thrombectomy-capable and comprehensive stroke centres.

Back in February 2018, the Joint Commission announced revised eligibility requirements for the Thrombectomy-Capable Stroke Centre (TSC) certification program. The revised eligibility included a requirement for all primary neuro-interventionists (i.e., those who routinely take call to perform emergency mechanical thrombectomy) to either be certified by the Committee for Advanced Subspecialty Training (CAST) or to meet similar criteria, including education, training, and experience performing 15 mechanical thrombectomies over the past 12 months or 30 over the past 24 months. In the May 2018 edition of Perspectives, the Joint Commission announced that this same requirement would be applied to Comprehensive Stroke Centres.

Since the publication of these revised eligibility criteria, a number of individuals and organisations have raised concerns about the individual physician training requirement for CAST certification or the equivalent. First, many expressed that the requirement is overly stringent and is not necessary to ensure that patients at TSCs and CSCs receive high quality mechanical thrombectomy because CAST certification requires training and ongoing experience in a number of procedures other than mechanical thrombectomy (e.g., interventions for aneurysms and arteriovenous malformations).

Second, the training requirement excludes many highly qualified individuals, i.e., interventional radiologists who have training and experience in neurovascular interventions and have been performing mechanical thrombectomy successfully for years. The Joint Commission originally thought these individuals could become CAST certified through the Practice Pathway; however, this is not possible for them because they are not doing other neuroendovascular procedures required for individual CAST certification.

SIR president M Victoria Marx, an interventional radiologist at Keck Medicine of the University of Southern California, USA, said, “SIR strongly believes that interventional radiologists have a current and growing role in the care of patients with ischaemic strokes. We stand committed to advocate for policy changes and provide the cognitive and technical skills and resources necessary for interventional radiologists to provide high-quality care.”

Thirdly, limiting eligibility with these requirements could adversely affect access to mechanical thrombectomy. One health care system said they had no physician in their system that met the training requirement. The system provided data showing that the clinical outcomes for their eight interventional radiologists were similar to those reported in clinical trials.

In addition, the Society of Interventional Radiology sponsored an independent analysis of which specialties were performing mechanical thrombectomies for Medicare patients. Of the 5,914 claims, 37% were performed by physicians who identified themselves as diagnostic radiologists, 27% by neurosurgeons, 20% by neurologists, and 16% by interventional radiologists.

Concerns have also been raised pertaining to the individual physician volume requirement of 15 mechanical thrombectomies over the past 12 months or 30 over the past 24 months, adopted by the Joint Commission based on CAST requirements. Analyses conducted by one healthcare system showed that only three of the eight interventional radiologists in their system were at or near this benchmark.

The CAST volume requirement was adopted by the Technical Advisory Panel of the Joint Commission because it was a concrete benchmark used by a national organisation.

However, the panel acknowledged that there were no adequately powered studies available to determine a distinct threshold for a physician volume-outcome relationship.

In addition, SIR sponsored an independent analysis of the 2016 Centers for Medicare and Medicaid Services (CMS) Physician Supplier and Provider Services (PSPS) files and Provider Utilization File (PUF). Of the 995 physicians who billed under code 61645 (percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injections), 842 (85%) billed for 10 or fewer procedures. For the 153 (15%) physicians who performed more than ten procedures, the median number of procedures was still only 15.

This analysis is limited because it does not include procedures billed to private insurers or Medicare advantage plans, the procedures under the target billing code are heterogeneous, and the data are from 2016 when the indications for mechanical thrombectomy were more restrictive than current ones. Despite these limitations, the data raise important questions about whether the current individual physician volume requirements for the TSC and CSC certification programmes would exclude too many qualified individuals.

The Joint Commission and the American Heart Association believe that additional dialogue is needed with national stakeholder organisations to discuss individual physician training and volume requirements.

For these reasons, the Joint Commission suspended the individual physician training and procedure volume requirements for both the TSC and CSC certification programmes, in September 2018. The facility volume requirement of 15 mechanical thrombectomies per year will still be in force for both certification programmes, however. In an Autumn statement, the Joint Commission said: “We hope to establish new, more appropriate individual physician requirements within the next six months.”

Stroke affects 16.9 million worldwide each year, with 795,000 new cases in the USA annually. Approximately 100,000 of the US cases are eligible for EVT treatment, yet only a fraction are treated due to the shortage of thrombectomy-capable stroke centres. To meet that volume, the USA would need 500 endovascular stroke centres and 2,000 physicians. It currently has 231 thrombectomy-capable stroke centres.

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