Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke
Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke
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DOI：
10.1016/j.jvir.2017.11.026
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发表时间：
2018-08-01
影响因子：
6.7
通讯作者：
Vorwerk, Dierk
中科院分区：
文献类型：
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作者：
Sacks, David;Baxter, Blaise;Vorwerk, Dierk
最近在几项临床试验中证明了血管内治疗（EVT）对选定患者的急性缺血性卒中的有效性，并且血栓切除术已开始广泛应用于常规临床实践。然而，这些急性中风服务是资源密集型的，包括先进的脑成像和训练有素的多学科医院团队迅速响应紧急激活。尽管之前接受静脉内纤溶治疗急性缺血性卒中，并建立了指定的卒中中心（1），但缺血性卒中仍然是成人死亡和残疾的主要原因（2）。许多患者不是纤溶的候选者，并且静脉内治疗对于由于大的脑动脉闭塞而导致的严重中风相对无效。此外，尚不确定试验环境中血管内卒中治疗的受益是否可以推广到由不同培训、经验和病例量的医院和团队提供的临床护理。在其他医学学科中，快速的技术进步需要有效和负责任地使用这些工具的指导方针（3）。2013年，一个多社会、多专业、国际共识小组发表了血管内缺血性卒中治疗结局的质量改善（QI）指标（4）。这些QI指标已在英国和爱尔兰（5）的国家层面上被接受，但尚未纳入美国卒中中心认证要求。继之前的QI指南发布后，又发布了8项随机试验和几项EVT荟萃分析（6-20）。这些随机试验已经将EVT确立为可用的标准治疗（5，21-23），并提供了更新先前论文的指标和基准的额外数据（4）。因此，现在可以根据新的证据修改之前的QI文件。本QI共识声明的修订仍然侧重于护理流程和患者结局。其他文件涉及医生培训标准（24，25）和患者选择和治疗方法的建议（5，23）。与之前的指南一样，这些基准预期用于质量改进项目，以评估和改进急性卒中血运重建的过程和结局。基准提供了卒中治疗学术行业圆桌会议（STAIR）IX学术行业圆桌会议要求的下一代血管内试验的共识过程和结局共识措施（26）。这些基准也可能适用于中风干预计划的认证。大多数指标适用于介入医生的角色，无论专业或特定的委员会认证，但全面的中风护理需要一个广泛的多学科过程，涉及护理范围从紧急派遣护理人员到急性医院护理和治疗后亚急性康复。因此，尽管本文件的目的不是详细评估设施的质量，但一些指标也适用于中风护理的机构政策和程序。
Endovascular therapy (EVT) for acute ischemic stroke in selected patients has recently been proven effective in several clinical trials, and the widespread adoption of thrombectomy into routine clinical practice has begun. However, these acute stroke services are resource-intensive, including advanced cerebral imaging and highly trained multidisciplinary hospital teams rapidly responding to emergency activation. Despite the previous acceptance of intravenous fibrinolysis for acute ischemic stroke and the development of designated stroke centers (1), ischemic stroke remains a leading cause of adult death and disability (2). Many patients are not candidates for fibrinolysis, and intravenous therapy is relatively ineffective for severe strokes as a result of large cerebral artery occlusions. Moreover, it is uncertain if the benefits of endovascular stroke treatment in the trial setting can be generalized to clinical care provided by hospitals and teams of varying training, experience, and case volume. In other medical disciplines, rapid technologic advancement required guidelines to utilize these tools effectively and responsibly (3). Quality-improvement (QI) metrics for the outcomes of endovascular ischemic stroke treatment were published by a multisociety, multispecialty, international consensus group in 2013 (4). These QI metrics have been accepted at a national level in Great Britain and Ireland (5) but have yet to be included into stroke center accreditation requirements in the United States. Subsequent to the publication of the prior QI guidelines, 8 randomized trials and several meta-analyses of EVT have been published (6–20). These randomized trials have established EVT as standard of care when available (5, 21–23), and provide additional data on which to update the metrics and benchmarks of the previous paper (4). Therefore, it is now appropriate to revise the prior QI document based on new evidence. Revision of this QI consensus statement remains focused on processes of care and patient outcomes. Other documents address standards for physician training (24, 25) and recommendations for patient selection and treatment methods (5, 23). As in the previous guidelines, it is intended that these benchmarks be used in a quality-improvement program to assess and improve processes and outcomes in acute stroke revascularization. The benchmarks provide the consensus process and outcome consensus measures called for by the Stroke Treatment Academic Industry Roundtable (STAIR) IX academic industry roundtable for the next generation of endovascular trials (26). The benchmarks may also be suitable for accreditation of stroke intervention programs. Most of the metrics apply to the role of the interventional physician, regardless of specialty or particular board certification, but comprehensive stroke care requires a broad multidisciplinary process involving care that ranges from emergency dispatch of paramedics through acute hospital care and posttreatment subacute rehabilitation. Therefore, although it is not the intention of this document to assess in detail the quality of facilities, some of the metrics also apply to institutional policies and procedures for stroke care.