Three physicians published an editorial in Stroke proposing that tertiary healthcare centers in cities be held to stricter standards for performing endovascular thrombectomy (EVT) than their rural counterparts.
This two-tiered approach would work better than setting a single bar that is too high or too low, wrote Mayank Goyal, MD, Kathinka D. Kurz, MD, and Mark Fisher, MD.
“By setting a universally lenient bar (which is being suggested by some organizations), we do solve the problem of allowing centers to be created and some level of service to be provided in the less populated areas, but we risk … unnecessarily diluting the optimal outcomes that can be achieved in cities by appropriate triage,” the researchers wrote. “This will result in many centers having lower volumes, unable to sustain the required level of infrastructure, teamwork and 24/7 service.
“The risk of setting the bar high, as is being recommended by some societies, is that centers outside big cities will not have a sufficient volume and may not be able to attract the necessary talent. It also prevents/delays access to populations of some jurisdictions/countries that are just starting to perform EVT.”
Striking an appropriate balance between the timing and quality of treatment is particularly important in the case of acute ischemic stroke, because EVT outcomes have been strongly associated with both the speed with which reperfusion is achieved and the quality or completeness of that reperfusion.
Goyal and colleagues said additional data is needed to show that EVT at a low-volume center is better than no EVT at all or substantially delayed treatment for the time it takes to transport a patient to a higher-volume facility.
Nevertheless, in the interest of growing the number of proceduralists and centers capable of performing EVT, they suggested the standards for case volumes and workflow parameters be set “much lower” for centers in less-densely populated areas compared to those in cities.
“However, the bar for the hospital to allow sufficient opportunity for the team to have continued medical education, the opportunity to collaborate and learn from high volume centers, keep up their skill set using simulation tools, etc. should remain reasonably high,” the editorialists wrote. “In addition, these centers will be expected to maintain excellent records and be subject to audits to demonstrate that the results of the randomized trials are being replicated.”
The tertiary centers could help the rural centers through training courses, educational sessions focused on complications and difficult cases and also through live videoconferencing during patient triage and treatment.
“We have but one opportunity to set this up correctly,” the authors concluded. “It is much easier to make appropriate recommendations now as EVT for stroke is starting to expand rather than let it devolve into chaos and then restructure the system later on.”