Quality improvement for diagnostic neuroangiography and other procedures.

THE Quality Improvement Guidelines for Adult Diagnostic Neuroangiography published in this issue of JVIR (1) is a clinical practice guideline produced by an interdisciplinary consensus group process to cover a crucial aspect of the care of patients with potentially devastating neurovascular disease. The document should be of intense interest to all those who desire to ensure quality of care for patients undergoing carotid angiography. As the pace of development and application of carotid stent placement and intracranial thrombolysis quickens, it is important to remember that one major potential rate-limiting factor in ensuring efficacy and safety of these procedures is the training, skill, and experience of practitioners performing the diagnostic and interventional components of the procedures. Outcomesbased practice guidelines such as this one must be used to monitor results and set a benchmark for expected performance. Clinical practice guidelines are defined as systematically developed statements, which assist medical decision making. Besides quality improvement guidelines such as this one, other practice guidelines include credentialing statements and clinical pathways. Guidelines are used primarily to reduce variation in clinical practice between individual physicians or groups of physicians, thus raising the standard of care. Guidelines also assist physicians and other healthcare providers in managing the huge amount of information that is found at scientific meetings, in journal articles, and in personal clinical experiences. Clinical practice guidelines serve both an educational and a surveillance function in an effort to define and achieve an optimum level of patient care. Good practice guidelines should rest on methodical analysis of the scientific evidence, be reproducible and reliable, have clinical applicability for defined patient populations, and be updated periodically to reflect current knowledge and state of practice. We believe that this neuroangiography practice guideline meets these criteria. The quality improvement guidelines on neuroangiography comprise the first intersociety, multidisciplinary document developed by the ASNR, ASITN, and the SIR. Members of these societies together have had the overwhelming clinical experience with carotid arteriography in the United States. Radiologists (including vascular and interventional radiologists, neuroradiologists, and interventional neuroradiologists) performed 91% of the 91,558 cervicocerebral angiograms recorded in the Medicare procedural database in one recent year, while physicians in the next named specialty category (cardiology) performed only 4.2% (2). Therefore, these radiology groups possess the clinical experience and expertise to generate a realistic standard of care. The membership of the intersociety working committee represents both academic and community practices and was drawn from a wide geographic area. Quality improvement documents such as this one, as well as others in the SIR QI program (3–7), utilize an evidence-based literature search and a formalized consensus process (modified Delphi technique), which provide valid and reproducible threshold indicators. Thresholds defined by the document are appropriateness (indications), effectiveness (technical success), and safety (complication rate) (8,9). Preliminary data from the SIR HI-IQ electronic database have been used to provide actual clinical practice data on short-term outcomes and will be used in the future to validate and update quality improvement guidelines. There are multiple sources for practice guidelines, including hospital protocols and bylaws, payers, national, local and state health care agencies, professional societies, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In recent years, JCAHO compliance and consequent accreditation has been of paramount concern to healthcare organizations. The JCAHO requires that there is a mechanism that ensures that the same level of quality of patient care be provided by all individuals with delineated clinical privileges, both within medical staff departments and across all departments at an institution (10). Thus, outcome measures as delineated This article first appeared in J Vasc Interv Radiol 2000; 11:1–3.