Consistency in endovascular aneurysm repair suitability assessment requires group decision audit

Abstract

Introduction: Proper selection of patient and stent-graft combinations in endovascular aneurysm repair (EVAR) depends on knowledge and experience with the different types of stents that have to be adapted to the patient's unique abdominal aortoiliac anatomy. The aim of this study was to analyze the consistency and variance in EVAR suitability assessment between clinicians.

Methods: Worksheets that contained anatomic data derived from computed tomography scans and angiography were compiled for 202 patients. Five clinicians, all experienced in EVAR surgery, assessed the anatomic data on the worksheets for suitability for three types of stent-grafts. The obtained 3030 assessments represented a quantification of the likelihood of success the clinician expected for effective and durable sealing and fixation of the stent-graft in EVAR. The Delphi method was used to determine consensus in the thinking process among clinicians, and kappa analysis was used to determine the proportion of variances in the assessment result between clinicians.

Results: With the Delphi method, Cronbach alpha values of 0.87, 0.87, and 0.90 were reached for the three types of stent-grafts in the second assessment round. The individual clinician-group correlation in round two was between 0.69 and 0.86 for clinicians 1, 2, 3, and 4. Between clinician 5 and the others, correlation varied between 0.43 and 0.64. The kappa values ranged between 0.32 and 0.51 among clinicians 1, 2, and 3. Between clinician 5 and the others, kappa values between 0.08 and 0.29 were reached.

Conclusion: EVAR suitability estimation in a cohort of patients is highly consistent in a group of experienced clinicians. The EVAR suitability estimation at the individual patient level varies substantially between clinicians, however. Aggregating expert opinions in abdominal aortic aneurysm anatomic suitability assessment for EVAR had the opportunity to replace individual clinician decision diversification in a more solid and consistent group decision process.