Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting

Irish Journal of Medical Science (1971 -) https://doi.org/10.1007/s11845-023-03319-4 ORIGINAL ARTICLE Frequency of inter‑specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting Chika Offiah1,2 · Sean Tierney3 · Bridget Egan3 · Ronán D. Collins2,4 · Daniel J. Ryan2,4 · Allan J. McCarthy1,2 · Deirdre R. Smith1,5 · James Mahon2,4 · Emily Boyle3 · Holly Delaney6 · Rory O.’Donohoe6 · Alison Hurley6 · Richard A. Walsh1 · Sinead M. Murphy1,2,9 · Petya Bogdanova‑Mihaylova1 · Sean O.’Dowd1 · Mark J. Kelly1,2 · Taha Omer1,2 · Tara Coughlan2,4 · Desmond O.’Neill2,4 · Mary Martin7 · Stephen J. X. Murphy1,2 · Dominick J. H. McCabe1,2,5,8,10 Received: 2 December 2022 / Accepted: 13 February 2023 © The Author(s) 2023 Abstract Background/aims Data are limited on the frequency of ‘consensus decisions’ between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM ‘adherence’ to such advice. Methods This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom ‘consensus management decisions’ were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), ‘indeterminate symptomatic status stenosis’ (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / − intervention. Results One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50–99% SCS patients was 12.5 days (IQR: 9–18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1–7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up. Conclusions The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death. Keywords Carotid endarterectomy and endovascular treatment · Neurovascular multidisciplinary team meeting · Optimal medical therapy · Stroke · TIA Introduction The late Dr Holly Delaney, was instrumental to the successful conduct of our Neurovascular Multidisciplinary Meeting, and in collection and interpretation of the neuroradiogical and neurovascular imaging data. We dedicate this work to her. * Dominick J. H. McCabe Extended author information available on the last page of the article National and international guidelines recommend that decisions regarding surgical or endovascular intervention in patients with extracranial carotid or vertebral artery stenosis should be made by a multidisciplinary team (MDT), preferably including a neurologist or stroke physician, vascular surgeon and a neuroradiologist [1, 2]. It has also been recommended that suitable patients with ≥ 50% symptomatic 13 Vol.:(0123456789) Irish Journal of Medical Science (1971 -) carotid artery stenosis (SCS) be considered for revascularisation within 2 weeks of symptom onset [2–5], with careful selection of higher risk patients with ≥ 60% asymptomatic carotid stenosis (ACS) who may warrant revascularisation [2, 5]. Expert consensus advice from the ESO 2021 guidelines on endarterectomy and stenting for carotid artery stenosis suggests that the independently-assessed in-hospital risk of peri-operative stroke or death following endarterectomy for SCS patients should ideally be ≤ 4%, with corresponding risks of ≤ 2% in ACS patients [5]. The ESVS 2017 and ESVS 2023 guidelines recommend that the 30day peri-procedural risk of stroke or death in patients with 50–99% SCS who undergo revascularisation should be ≤ 6%, with corresponding risks of ≤ 3% in patients with ≥ 60% ACS [2], [6]. Neurovascular multidisciplinary team meetings (MDMs) have the potential to improve the selection of individual asymptomatic and symptomatic patients who are best suited to optimal medical or interventional treatment, referral for inclusion in ongoing research studies/trials, or a combination of these options to optimise protection against transient ischaemic attack (TIA) or stroke [7–10]. However, some surgeons or interventional neuroradiologists without an established MDM at their hospital might be concerned that discussion of their patients at such meetings might actually reduce the number of patients selected for revascularisation. These concerns may be understandably fuelled by the paucity of available data on the frequency of consensus opinion amongst different subspecialists at MDMs, on the adherence to the advice offered and on clinical outcomes following discussion at such meetings. Aims The aims of this multi-centre audit and quality assessment and improvement process were the following: 1. Assess the proportion of patients in whom a consensus management decision was reached by the attending surgeons and physicians from different specialities. 2. Assess the ‘adherence’ to the advice offered regarding treatment by the attending physician/surgeon after they had further discussions with the patient following the MDM. 3. Document the categories of medical or interventional advice provided to patients with extracranial carotid or vertebral artery stenosis at a neurovascular MDM. 4. Assess the time from symptom onset to MDM discussion and the time from MDM discussion to intervention, as appropriate. 5. Assess short- and medium-term outcomes in our cohort following MDM discussion. 13 Hypotheses We hypothesised the following: 1. Consensus decisions regarding management would be reached in the majority of patients. 2. Most treating physicians/surgeons and patients would ‘adhere’ to the primary treatment advice offered at the neurovascular MDM. 3. The majority of SCS patients would have revascularisation and the majority of ACS and vertebral artery stenosis (VAS) patients would have optimal medical treatment as their primary recommended treatment. 4. Our practice would be in keeping the international guidelines regarding optimal time from symptom onset and MDM discussion + / − intervention, where necessary. 5. Outcome event rates before discharge and (...truncated)