Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke

Background and Purpose: Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke among Medicare beneficiaries Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals. Results: Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams. Conclusions: Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.