Robert Fahed1, André L Batista1, Tim E Darsaut2, Jean-Christophe Gentric3, Célina Ducroux1, Chiraz Chaalala4, David Roberge5, Michel W Bojanowski4, Alain Weill1, Daniel Roy1, Elsa Magro6, Jean Raymond7. 1. Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, 1560 Sherbrooke East, Pavilion Simard, suite Z12909, H2L 4M1 Montreal, Quebec, Canada. 2. University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Edmonton, Alberta, Canada. 3. Centre hospitalo-universitaire Cavale Blanche, Department of Radiology, Division of Neuroradiology, EA 3878 GETBO, Brest, France. 4. Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Neurosurgery, Montreal, Quebec, Canada. 5. Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radio-Oncology, Montreal, Quebec, Canada. 6. Centre hospitalo-universitaire Cavale Blanche, Department of Surgery, Division of Neurosurgery, EA 3878 GETBO, Brest, France. 7. Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, 1560 Sherbrooke East, Pavilion Simard, suite Z12909, H2L 4M1 Montreal, Quebec, Canada. Electronic address: jean.raymond@umontreal.ca.
Abstract
OBJECT: The best management of brain arteriovenous malformation (bAVM) patients remains unknown. Randomized allocation may be more readily accepted when there is uncertainty and disagreement regarding the management of potential participants. In planning for a trial, we aimed to assess variability and agreement among physicians managing bAVM patients. METHODS: A portfolio composed of 35 patients was sent to 47 clinicians of various specialties managing bAVM patients. For each patient, physicians were asked their best management decision (surgery/embolization/radiosurgery/conservative), their confidence level, and whether they would include the patient in a randomized trial comparing conservative and curative management. Seven physicians, who had access to all images of each patient, independently responded twice, to assess inter and intra-rater agreement using kappa statistics. RESULTS: The inter-rater agreement (30 raters, including 16 neuroradiologists) for best management decision was only "fair" (κ [95%CI]=0.210[0.157; 0.295]). Agreement remained below 'substantial' (κ<.6) between physicians of the same specialty, and when no distinctions were made between various treatments (when responses were dichotomized as conservative versus curative). With access to all images the inter-rater agreement remained fair. The intra-rater agreement reached "substantial" only for the dichotomized decisions. Responding clinicians were willing to include 54.4% of patients (mainly unruptured bAVMs) in a randomized trial. CONCLUSION: There is a lack of agreement among clinicians involved in the management of bAVM patients. In this study a substantial proportion of clinicians were willing to offer randomized allocation of management options to a substantial number of patients.
RCT Entities:
OBJECT: The best management of brain arteriovenous malformation (bAVM) patients remains unknown. Randomized allocation may be more readily accepted when there is uncertainty and disagreement regarding the management of potential participants. In planning for a trial, we aimed to assess variability and agreement among physicians managing bAVM patients. METHODS: A portfolio composed of 35 patients was sent to 47 clinicians of various specialties managing bAVM patients. For each patient, physicians were asked their best management decision (surgery/embolization/radiosurgery/conservative), their confidence level, and whether they would include the patient in a randomized trial comparing conservative and curative management. Seven physicians, who had access to all images of each patient, independently responded twice, to assess inter and intra-rater agreement using kappa statistics. RESULTS: The inter-rater agreement (30 raters, including 16 neuroradiologists) for best management decision was only "fair" (κ [95%CI]=0.210[0.157; 0.295]). Agreement remained below 'substantial' (κ<.6) between physicians of the same specialty, and when no distinctions were made between various treatments (when responses were dichotomized as conservative versus curative). With access to all images the inter-rater agreement remained fair. The intra-rater agreement reached "substantial" only for the dichotomized decisions. Responding clinicians were willing to include 54.4% of patients (mainly unruptured bAVMs) in a randomized trial. CONCLUSION: There is a lack of agreement among clinicians involved in the management of bAVM patients. In this study a substantial proportion of clinicians were willing to offer randomized allocation of management options to a substantial number of patients.
Authors: Robert Fahed; Tim E Darsaut; Charbel Mounayer; René Chapot; Michel Piotin; Raphaël Blanc; Vitor Mendes Pereira; Daniel G Abud; Dana Iancu; Alain Weill; Daniel Roy; Lorena Nico; Suzanne Nolet; Guylaine Gevry; Jean Raymond Journal: Interv Neuroradiol Date: 2019-02-04 Impact factor: 1.610