IMPROVE Decision Rule for Carotid Revascularization: Clinician Perspectives on Acceptability and Implementation Barriers

Background: Current selection of patients for carotid revascularization is mainly based on neurological symptoms and the degree of carotid artery stenosis. The IMPROVE decision rule can improve the identification of high-risk patients that may benefit from carotid revascularization. Clinicians dealing with stroke patients must be able to rely on the IMPROVE decision rule during clinical trials to validate the clinical benefits. We assessed the level of acceptance, but also possible barriers for implementation of the IMPROVE decision rule among clinicians in the Netherlands. Methods: We conducted qualitative semi-structured individual interviews with 40 clinicians involved in stroke care, working in the Department of Neurology (n=18), Vascular Surgery (n=12) or Radiology (n=10) across 10 Dutch academic and non-academic medical centers. 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 (72.5%) clinicians agreed, five (12.5%) clinicians (three neurologists, two radiologists) strongly agreed, and another six (15%) clinicians (three neurologists, three vascular surgeons) neither disagreed nor agreed with the proposition. Our analysis identified twelve barriers to acceptability for the IMPROVE decision rule that could be grouped into four categories of origin: lack of evidence, limited clinical practicality, insufficient familiarity, and healthcare burden. Conclusion: Most clinicians accepted IMPROVE but emphasized 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 revascularization selection with current clinical practice is necessary to demonstrate beneficial patient outcomes.