Patients will benefit from a higher and more consistent standard of care, its creators said.
For the first time, three competing specialties—neurology, neurosurgery, and radiology—have come together to set standards for training in neuroendovascular therapy. These new standards, published in the August 2017 issue of Stroke, are designed to raise the bar in neuroendovascular care, with the goal of improving patient outcomes.
Lead author Steven Giannotta, MD (University of Southern California, Los Angeles, CA), told Neurovascular Exchange that the document “represents a greater collaboration and consensus of the three subspecialties of medicine that practice neurointerventional stroke techniques: neuroradiologists, neurologists, and neurosurgeons. [We] recognized that it did not make a lot of sense for each to have different training standards and backgrounds before being trained in neuroendovascular techniques. It did not serve the public as well as it might.” Moreover, he added, “there was no reason to have a competition among the three different practice groups.”
Until now, operators could be hired by hospitals lacking a comprehensive stroke program on a somewhat ad hoc basis to perform neuroendovascular interventions, explained Giannotta. Lacking an overarching body to promulgate a single standard, the only official requirement was completion of a fellowship program, regardless of whether that fellowship was accredited. This made it difficult to control quality of care.
“We saw a lot of potential abuses in the system, and we thought it was a good idea to come to a consensus and publish it in hopes that we get communities, hospitals, and stroke practitioners to resonate to the idea of a common standard,” he said.
Under the aegis of the Society of Neurological Surgeons (SNS) and its Committee for Advanced Subspecialty Training (CAST) and in conjunction with the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery (SNIS), and the Society of Vascular and Interventional Neurology (SVIN), experts came to together to develop detailed requirements.
- CAST neuroendovascular surgery training programs: To receive accreditation, programs must exist within or be closely affiliated with an Accreditation Council for Graduate Medical Education-accredited neurosurgical residency training program and possess specific resources, including an emergency room, a dedicated neurointensive care unit, accredited residency programs in neurology and radiology, and accredited fellowship programs in stroke and vascular neurology, neurocritical care, and neuroradiology. The program should perform at least 250 neuroendovascular procedures per year. Required personnel include an appropriately certified and experienced director or codirector as well as at least two faculty members with special expertise in neuroendovascular surgery.
- Individual training, including stages, timing, and duration: Each individual trainee must satisfy the requirements of their primary specialty training in radiology, neurosurgery, or neurology. Advanced training must provide the trainee the opportunity to perform a spectrum of at least 250 endovascular procedures as the primary operator. The standards list numerous skills that trainees must develop expertise in and provide detailed requirements regarding hours of training and numbers of procedures that must be performed.
- Individual neurovascular surgery training certification: Certification will be provided by CAST based on one of two pathways: (1) prior NES training and experience (Practice Track) and (2) satisfactory completion of training within a CAST-accredited NES training program.
Raising the Bar
“We have 113 neurointerventionalists certified by our CAST organization, and there are more applying every day,” said Giannotta. “We are definitely setting a higher bar than previously existed, and that’s all to the public good. We hope it upgrades [clinical care] and sets a template for all hospitals that want to get involved in acute stroke care.”
With the new standards, hospitals wishing to hire neurointerventionalists will have a much easier time vetting and tracking applicants’ credentials. This in turn gives operators a strong incentive to obtain the training needed to provide excellent care.
In an editorial, Stephen M. Davis, MD (University of Melbourne, Parkville, Victoria, Australia), and colleagues laud the requirements, pointing out that Australian guidelines for neurointerventionalist training are “similarly comprehensive and rigorous. Clearly, procedural volume and complexity correlate with efficacy and safety. Procedural outcomes should be audited independently.
“Many of us well remember the alarm bells ringing in the 1980s when some less experienced centers were reporting worrying stroke rates with carotid endarterectomy,” they say.
Source:
- Day AL, Siddiqui AH, Meyers PM, et al. Training standards in neuroendovascular surgery: program accreditation and practitioner certification. Stroke. 2017;Epub ahead of print.
- Davis SM, Campbell BCV, Donnan GA, et al. Endovascular thrombectomy and stroke physicians: equity, access, and standards. Stroke. 2017;Epub ahead of print.
Disclosures:
Gianotta and Davis report no relevant conflicts of interest.