- Strategies are needed to compensate physicians adequately, reduce the risk of burnout and optimize patient triage and selection
- In a prospective study at nine stroke centers, physicians spent about 69 minutes per 24-hour call on thrombectomy-related duties
- 71% of thrombectomies performed during work hours resulted in delays of at least 30 minutes in elective procedures or clinic appointments
- In 61% of instances when the neurointervention team was activated, it was decided that thrombectomy was not needed
- 60% of thrombectomies occurred during non-work hours, and for 51%, physicians had to emergently travel from outside the hospital
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Now that mechanical thrombectomy is the standard of care for emergent large vessel occlusions, stroke centers are seeing a markedly greater number of cases. That trend is likely to accelerate because of the DAWN and DEFUSE 3 trials, which showed functional benefit in certain patients undergoing endovascular revascularization as many as 24 hours after symptom onset.
Neurothrombectomy consultations are often needed outside regular work hours, most commonly between 8:00 pm and 9:00 pm, according to a 2016 retrospective study at 10 U.S. stroke centers. About two to three hours typically elapsed between contact with the attending physician and completion of all thrombectomy-related duties.
However, the retrospective study did not include "false-positive" cases—those in which a neurointerventional team was appropriately activated but decided not to proceed with thrombectomy.
To more accurately assess the burden of neurothrombectomy calls, nine stroke centers (including eight of the original 10) conducted a prospective study reported in the Journal of NeuroInterventional Surgery. The authors conclude that a thrombectomy call is burdensome to physicians in terms of total hours, time required outside normal work hours and disruption of other scheduling.
Mass General physicians, Thabele Leslie-Mazwi, MD, specialist in Neuroendovascular and Neurocritical Care, and Joshua A Hirsch, MD, co-director of the Neuroendovascular Program, and colleagues collected data on 270 days of calls (30 consecutive days at each of the nine centers) between May and September 2017. Altogether, 214 consultations were made, 84 proceeded to thrombectomy and 130 were false-positives (61%).
The median total time for the consultation and immediate related duties (except for dictation) was 171 minutes (average, 191 minutes), the researchers found. The median overall time burden per 24-hour call period was 69 minutes (average, 85 minutes).
All told, 60% of all consultations and 60% of thrombectomies occurred during non-work hours, interfering with the physicians' personal lives. Moreover, 15% and 18%, respectively, occurred between 10:00 pm and 6:00 am. For 43 of the 84 thrombectomies (51%), the physician had to emergently commute to the hospital.
Wreaking further havoc with schedules, 71% of the thrombectomies during work hours resulted in at least a 30-minute delay in scheduled elective procedures or clinic appointments. In some cases, resource limitations compounded the delay (e.g., anesthesia availability for a delayed elective case).
The researchers combined the data from this prospective study with the results of the retrospective study, for the eight centers that participated in both. In 2017, the rate of thrombectomy was about one in every three days, up from about one in every five days in the prior study. Seven of the eight centers (88%) had a higher rate of thrombectomy in 2017 than in 2016.
The authors say it is crucial to compensate neurothrombectomy providers appropriately so physicians do not reduce or stop taking calls, as has happened in cardiology with percutaneous coronary intervention. As thrombectomy volumes increase, strategies will be necessary to reduce the risk of physician burnout and optimize triage and selection.
Learn about stroke care at Mass General
Learn about the Cerebrovascular Program at Mass General