Uncertainty and agreement in the management of unruptured intracranial aneurysms

Abstract

Object The management of unruptured intracranial aneurysms remains controversial. The goal of this study was to evaluate the clinical community agreement in decision making regarding unruptured intracranial aneurysms. Methods A portfolio of 41 cases of unruptured intracranial aneurysms with angiographic images, along with a short description of the patient presentation, was sent to 28 clinicians (16 radiologists and 12 surgeons) with varying years of experience in the management of unruptured intracranial aneurysms. Five senior clinicians responded twice at least 3 months apart. Nineteen cases (46%) were selected from patients recruited in the Canadian UnRuptured Endovascular versus Surgery trial, an ongoing randomized comparison of coil embolization and clip placement. For each case, the responder was to first choose between 3 treatment options (observation, surgical clip placement, or endovascular coil embolization) and then indicate their level of certainty on a quantitative 0–10 scale. Agreement in decision making was studied using κ statistics. Results Decisions to coil were more frequent (n = 612, 53%) than decisions to clip (n = 289, 25%) or to observe (n = 259, 22%). Interjudge agreement was only fair (κ = 0.31 ± 0.02) for all cases and all judges, despite substantial intrajudge agreement (range 0.44–0.83 ± 0.10), with high mean individual certainty levels for each case (range 6.5–9.4 ± 2.0 on a scale of 0–10). Agreement was no better within specialties (surgeons or radiologists), within capability groups (those able to perform endovascular coiling alone, surgical clipping alone, or both), or with more experience. There was no correlation between certainty levels and years of experience. Agreement was lower when the cases were taken from the randomized trial (κ = 0.19 ± 0.2) compared with nontrial cases (κ = 0.35 ± 0.2). Conclusions Individuals do not agree regarding the management of unruptured intracranial aneurysms, even when they share a background in the same specialty, similar capabilities in aneurysm management, or years of practice. If community equipoise is a necessary precondition for trial participation, this study has found sufficient uncertainty and disagreement among clinicians to justify randomized trials.

Shared decision-making in the context of unruptured intracranial aneurysms management

“…Interventional neuroradiologists and neurosurgeons usually rely on variables like patient age, operative risk factors, aneurysm size, morphology, location, growth rate, and intra-aneurysmal flow patterns to support their decisions regarding UIA management. However, substantial disagreement between doctors on management of UIA has been recently reported 8,9,10 , which suggests that doctors are not absolutely or uniformly sure about their beliefs on the management of UIA.…”

“…Because of the subjective desires of patients and the variable indications of doctors 8,9,10 , we do not believe that a shared decision-making classification system, as described above, could generate specific scientific hypothesis for randomized trials. Nevertheless, whether study's results could be influenced by shared decisions before enrollment in trials is unknown, and it has to be demonstrated.…”

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms

“…With cost containment being a national priority, 6 demonstrating the financial viability of new treatment options is crucial. [7][8][9][10][11][12][13][14][15][16][17] Several studies have analyzed the economic aspects of cerebral aneurysm interventions. [18][19][20][21][22][23] However, the generalizability of their findings is limited because most authors failed to adjust appropriately for measured or unmeasured confounders.…”

Equipoise dumbbell

“…We ask, can you ever have ‘true’, idealized equipoise for all physicians and subjects involved even for a fleeting moment? These potential trials are anything but trivial and would definitely move the field forward, including randomized clinical trials comparing observation to treatment for unruptured aneurysms,14 the use of balloon guiding catheters in acute stroke,15 or the role of general anesthesia versus conscious sedation in acute stroke 16. One can effortlessly identify proponents on either end of the spectrum for each of these studies, and we need have no fear that we are being unethical by participating in a trial where patients are well-informed and the community of experts has not reached consensus.…”