In the Spotlight
Public Statement from the Society of NeuroInterventional Surgery, Joint Cerebrovascular Section of the AANS and CNS, and Society of Vascular and Interventional Neurology
Elimination of Key Requirements for Comprehensive Stroke Centers and Thrombectomy-Capable Stroke Centers Puts Patients at Risk
October 17, 2018  - 
The Joint Commission (TJC) has announced that it will abandon formal training and experience standards for physicians performing mechanical thrombectomy at Comprehensive Stroke Centers (CSCs) and Thrombectomy-Capable Stroke Centers (TSCs). Under the new standards, physicians performing thrombectomy do not need to be certified by the Society of Neurological Surgeons’ Committee on Advanced Subspecialty Training (CAST), which includes equal multi-specialty representation from neuroradiology, neurology and neurosurgery, nor do they need to meet a minimum caseload threshold.  TJC had previously endorsed a standard that recognized the importance of training and experience.
 
TJC explained that the decision was based on the concerns voiced by several unnamed individuals and organizations, and TJC supported their decision by citing privately commissioned, unpublished studies of physician billing and volumes by specialty. 
 
“While well intended, the recent changes to CSC and TSC standards, unfortunately, fall well below the mutually agreed upon standards of the national neurovascular organizations. These changes will limit patients’ and frontline healthcare providers’ confidence that the doctors performing lifesaving stroke surgery have appropriate training or can demonstration adequate expertise. This is a step backward in developing our U.S. stroke systems of care,” said J Mocco, MD, MS, chair of the Joint Cerebrovascular Section of the American Association of Neurological Surgeons and Congress of Neurological Surgeons.
 
Stroke patients who require urgent intervention must be triaged and transported to centers staffed by neurointerventionalists who have the best training and most experience. In a 2017 literature review published in the Journal of NeuroInterventional Surgery, Fargen et al., cite four peer-reviewed research studies that suggest a direct correlation between endovascular volume and patient outcomes — both for individual practitioners and for institutions.[1]  The same review references three studies that show lower-volume stroke centers report lower rates of positive outcomes when compared to higher-volume centers. Additionally, a 2011 Journal of the American Medical Association study showed 1.9 greater odds of 30-day mortality in patients who were treated by low-volume facilities.[2]  
 
Additionally, nearly all of the cases enrolled in the ESCAPE and DAWN trials that demonstrated the benefit of thrombectomy were performed by formally trained neurointerventionalists who maintain high caseload volumes. A critical appraisal of this evidence indicates that we simply do not know if the research outcomes from ESCAPE and DAWN would be the same had the procedures been done by physicians without formal neurointerventional training and high caseload volumes.
 
“Stroke is the fifth leading cause of death in the United States and affects about 795,000 Americans each year. Patients who require stroke intervention — especially those experiencing Emergent Large Vessel Occlusion (ELVO) and hemorrhagic strokes — must be triaged to centers with care teams that have extensive training and experience. Ultimately, patients will pay the price as a result of changes to CSC and TSC training and experience standards,” said Italo Linfante, MD, FSVIN, FAHA, president of the Society of Vascular and Interventional Neurology (SVIN).
 
Society of NeuroInterventional Surgery (SNIS) president Adam S. Arthur, MD, MPH noted that patients are more important than certification badges. “Stroke patients deserve timely, appropriate care provided by qualified physicians. In light of CSC and TSC eligibility changes, TJC standards should not be used when making patient triage decisions — patients must come first,” said Arthur.
 
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About the Society of NeuroInterventional Surgery
The Society of NeuroInterventional Surgery (SNIS) is a scientific and educational association dedicated to advancing the specialty of neurointerventional surgery through research, standard-setting, and education and advocacy in order to provide the highest quality of patient care in diagnosing and treating diseases of the brain, spine, head, and neck.  Visit http://www.snisonline.org and follow us on Twitter (@SNISinfo) and Facebook (@SNISOnline).
 
About the AANS/CNS Joint Cerebrovascular Section
The purpose of the Joint Cerebrovascular Section (CV Section) of the AANS and CNS is to advance education, research, and patient care in the area of vascular diseases of the brain. Through our activities and educational programs, we strive to promote awareness among all neurosurgeons of opportunities for clinical practice and research in the area of cerebrovascular surgery.  To learn more, please visit us at http://www.cvsection.org/.
 
About the Society of Vascular and Interventional Neurology
The Society of Vascular and Interventional Neurology is an international medical society whose mission is to represent the advancement of interventional neurology as a field with the ultimate goal of improving clinical care and outcomes of patients with stroke and cerebrovascular diseases. For more information about the Society of Vascular and Interventional Neurology, visit our website at http://www.svin.org
 

[1] Fargen KM, et al. Practice makes perfect: establishing reasonable minimum thrombectomy volume requirements for stroke centers. J NeuroIntervent Surg. 2017;9(8).

[2] Nallamothu BK, Gurm HS, Ting HH, et al. Operator experience and carotid stenting outcomes in Medicare beneficiaries. JAMA. 2011;306:1338–43.