Plaque Magnetic Resonance Imaging Based Decision Rule for the Selection of Symptomatic Patients for Carotid Revascularisation: Clinician Perspectives on Acceptability and Implementation Barriers in the Netherlands

Objective: At present, selection of patients for carotid revascularisation is mainly based on neurological symptoms and the degree of carotid artery stenosis. Individualised MRI based PRediction scOre using plaque Vulnerability for symptomatic carotid artEry disease patients (IMPROVE) can identify high risk patients who may benefit from carotid revascularisation, based on intraplaque haemorrhage, stenosis severity, cerebral symptoms, sex, and age. For use in clinical trials and eventual practice, the decision rule must be acceptable to clinicians. The level of acceptance and possible barriers to implementation of the IMPROVE decision rule were assessed among clinicians in the Netherlands. Methods: Qualitative semi-structured individual interviews were conducted with 40 clinicians involved in stroke care: 18 working in the department of neurology, 12 in vascular surgery, and 10 in radiology across 10 Dutch academic and non-academic medical centres. After an introduction to the IMPROVE decision rule, clinicians were queried regarding their stance on the proposition: “the IMPROVE clinical decision rule meets my approval”. Next, clinicians were queried about potential barriers expected in implementing this model in clinical practice. All interviews were transcribed and systematically coded to identify barriers to acceptability. Results: Twenty-nine (72%) clinicians agreed, five (13%) clinicians (three neurologists and two radiologists) completely agreed, and another six (15%) clinicians (three neurologists and three vascular surgeons) neither disagreed nor agreed with the proposition. This analysis identified 12 barriers to acceptability for the IMPROVE decision rule that could be grouped into four categories: lack of evidence, limited clinical practicability, insufficient familiarity, and healthcare burden. Conclusion: Most clinicians accepted IMPROVE but emphasised the need for clinical evaluation. A feasibility study is required to evaluate the clinical applicability of IMPROVE and its impact on healthcare burden. Additionally, a clinical trial comparing IMPROVE based revascularisation selection with current clinical practice is necessary to demonstrate beneficial patient outcomes.