You'll have to hope your stroke hospital has enforced standards for stroke surgeons. Or you'll have to ask your surgeon for proof of experience and success.
Stroke patients can’t ask for a second opinion: a multi-specialty response to The Joint Commission’s recent suspension of individual stroke surgeon training and volume standards
Statistics from Altmetric.com
If
you were considering surgery on your brain to stave off a devastating
stroke, you might ask about the training of the surgeon. You might ask
how many times they had done the procedure. Unfortunately, patients with
emergent large vessel occlusion strokes (ELVO) often cannot ask these
important questions. Even if they could, they lack the time to consider
their options. They depend on the healthcare system to bring them to a
surgeon who gives them the best chance.
On September 17
2018, The Joint Commission (TJC) announced the suspension of individual
physician training and volume requirements for acute ischemic stroke
thrombectomy at hospitals certified as Comprehensive Stroke Centers
(CSC) and Thrombectomy-Capable Stroke Centers (TCC). TJC decided to
remove its previously established requirement for both an individual
thrombectomy volume minimum and for physician-specific certification to
perform acute stroke thrombectomy. These requirements were established
based on multiple discussions of TJC’s own technical advisory panel
(TAP). No discussion was held with the TAP before the suspension of
training and volume requirements for individual physicians.
Why have individual requirements?
Initial
evidence to support these requirements can be found in the
multi-specialty recommendations for training by the Committee for
Advanced Subspecialty Training (CAST).1
These recommendations emphasize the importance of training and
experience for achieving optimal outcomes. As essential elements, the
CAST recommendations include: cognitive training in the clinical
neurosciences; critical procedural neuroendovascular training; and
annual performance of a minimum of thrombectomies and other
neuroendovascular procedures. These recommendations are based on a large
body of evidence published in peer-reviewed literature consistently
demonstrating that standards of training and case volumes for both
physician operators and treating medical centers significantly influence
procedural outcomes and should be requirements to ensure high-quality
care for patients.2–6
The physician volume requirement is further supported by the same 2016
Centers for Medicare and Medicaid Services (CMS) Physician Supplier and
Provider Services (PSPS) files and Provider Utilization File (PUF) cited
by TJC in their suspension of volume requirement justification. The
cited median volume of 15 thrombectomies for the physician cohort
with >10 thrombectomies does not take into account that Medicare
represented only 59% of thrombectomy patients.7
Simply adjusting for this differential raises the median to 25
thrombectomies. Additionally, the cited data do not account for the 30%
increase in CMS thrombectomy claims from 2016 to 2017 (2016=5905 versus
2017=7649). This would suggest the median total volume for those same
physicians would approximate to 35 in 2017. While 2018 data are not yet
available, it is hard to imagine that these thrombectomy numbers have
declined. By suspending physician training and volume requirements, TJC
has adopted a position that lacks evidentiary foundation and is
detrimental to patients.
Thrombectomy is effective… when performed by high-volume physicians who have undergone advanced subspecialty training
Level
1A evidence gathered from 10 randomized, controlled clinical stroke
trials has unequivocally proven thrombectomy superior to medical
management for acute ischemic stroke secondary to large vessel
occlusion.8–17
It is essential to realize that these studies required experienced
neuroendovascular physicians with established neurovascular clinical
expertise. Translation of the beneficial outcomes from such trials into
community practice without specialized physicians cannot be assumed. The
importance of specialty expertise and volume was so important to these
trials that, shortly after the trials’ publications, many of the
principal Investigators came together in 2015 to write an editorial
emphasizing this critical aspect of their studies.18
In this editorial, the authors emphasized, ’These data strongly suggest
that high-volume centers that frequently treat stroke patients achieve
better outcomes than low-volume hospitals that care for stroke patients
infrequently. The recently published trials all enrolled the vast
majority of their patients at such centers. As a result, it is
reasonable to assume that similar outcomes may not be obtained from
lower volume, less specialized hospitals.’ They further state that,
‘neurointerventionalists with appropriate expertise… are… critical
components’ to thrombectomy care, and that ‘inexperienced or low-volume
stroke hospitals will potentially jeopardize patient care and could lead
to worse outcomes.’ These authors, many of whom ran the definitive
trials providing evidence for thrombectomy, then concluded, ‘To ensure
attainment of trial results in actual practice, patients should receive
treatment at facilities certified as having the resources, personnel,
organization, and continuous quality improvement processes
characteristic of trial centers.’ The concept that low-volume,
non-credentialed practitioners can suffice to garner TCC or CSC
certification is as unrealistic now as it was in 2015.
The assumption that the benefit of acute stroke
thrombectomy performed by expert physicians persists for physicians who
lack neuroscience, cognitive, and procedural training, or who are
operating with low case volumes is flawed. Furthermore, this assumption
is not substantiated by published evidence and, if applied for
certification or credentialing purposes, almost certainly will result in
substandard patient outcomes.
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