Ask the Expert: New Collaborative Multi-Societal Credentialing Guidelines for Carotid Artery Stenting

Dr. Cates, you’ve been involved in helping the cardiology and vascular surgery societies develop credentialing guidelines for carotid artery stenting (CAS). How did these medical societies come together?

The societies felt it was important to take a role in helping define credentialing guidelines for CAS. Because this new procedure involves different anatomy and complications and because multiple specialists will be performing the procedure, a consistent set of guidelines will help to ensure the best patient care. So, the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Vascular Surgery (SVS), the Society for Vascular Medicine and Biology (SVMB) and the American College of Cardiology (ACC) came together to develop recommendations that clearly define training and credentialing guidelines for physicians on the pathway to CAS.

What were the major considerations in developing the guidelines?

CAS is a high-risk, high-visibility procedure which is technically challenging and will be performed by physicians from multiple specialties. The societies sought to achieve consensus on guidelines for minimum numbers of cerebral angiography and CAS procedures required to achieve competency. The guidelines also address how physician operator competency should be measured in an ongoing fashion and define the minimum industry standards for device certification, including the use of simulation.

What do the guidelines cover?

The topics include general principles for training in carotid artery intervention; cognitive, technical and clinical skills requirements; industry-sponsored device certification; the use of proficiency-based simulation; tracking of individual physicians’ outcomes; minimum facility and equipment standards; and recommendations for outcomes measurement and quality assurance. Could you give some specifics from the guidelines? Are there numbers of procedures that you’re recommending? The guidelines require that 30 supervised carotid angiograms should be performed prior to independent operator performance, with 15 cases performed as the primary operator. Once the angiogram criteria is met, then a minimum of 25 CAS procedures should be performed in a supervised setting prior to independent operator performance, with 13 CAS procedures as the primary operator. Included in the guidelines is a provision that allows for some of the carotid angiogram and CAS cases to be in the form of simulation training performed in a metric-based program to meet the recommendations. The guidelines also set minimum standards for industry-sponsored device training, including online didactic cognitive training, metric-based simulation training to proficiency, and proctoring.

What about monitoring physician performance in the CAS procedure?

We’re now working with the Centers for Medicare and Medicaid (CMS) to help determine how to monitor physician performance in an ongoing fashion after beginning CAS. The guidelines contain very important recommendations for tracking individual physicians’ and hospitals’ outcomes—this is very important. The societies proposed to CMS the creation of a mandatory reporting system that includes a national, independent, multi-societal database that will ultimately tie competency to clinical outcomes. The requirement for data collection in this database could also potentially be tied to future reimbursement for CAS.

Where can physicians and hospitals get the full set of guidelines?

The full set of guidelines has been published in the Journal of the American College of Cardiology (JACC), the Journal of Vascular Surgery (JVS), Catheterization and Cardiovascular Interventions (CCI), and the Journal of SCAI. They are also posted on the ACC and SCAI Web sites (www.acc.org and www.scai.org, respectively).

What impact do you expect the new guidelines to have on hospitals, physicians and patients?

These multi-societal guidelines will give credentialing criteria that can be adopted by hospitals and local medical groups as a minimum and consistent standard of training and competency in carotid angiography and stenting. We all know that the brain is not a forgiving organ, and operators who are not adequately trained in CAS will probably experience significant negative outcomes. The resulting patient morbidity and potential patient mortality could have a significant negative impact on the adoption of this innovative procedure.

What is significant about the guidelines and the multi-societal process by which they were developed? Does this set the stage for future collaboration?

This may be one of the most important sets of guideline recommendations developed in interventional medicine because it will help to define consistent cross-specialty competency standards and get more physicians on the pathway to performing CAS. The process by which these guidelines were developed could well be a model for future collaborations. The societies had similarly joined together in order to get a CPT^® code for CAS even before the procedure was FDA-approved. Certainly, effective societal collaboration is a lot of hard work but it is for the good of patients.

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