{"paper_id":"31432a7f-384f-4a71-9c5a-8e1d90c2f65b","body_text":"IMPROVE Decision Rule for Carotid Revascularization: Clinician Perspectives on Acceptability and Implementation Barriers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article IMPROVE Decision Rule for Carotid Revascularization: Clinician Perspectives on Acceptability and Implementation Barriers Juul Bierens, Stephanie Ament, Martine Truijman, Gert J. de Borst, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5917075/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Sep, 2025 Read the published version in European Journal of Vascular and Endovascular Surgery → Version 1 posted You are reading this latest preprint version Abstract 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. Neurology Carotid artery disease stroke MRI risk stratification decision rule Introduction Previous research has established that carotid revascularization procedures, carotid endarterectomy (CEA) and carotid artery stenting (CAS), can reduce the risk of recurrent ipsilateral stroke in symptomatic patients with ≥ 50% carotid stenosis. 1 , 2 However, these procedures carry perioperative risks with stroke rates of 4.4% for CEA and 7.2% for CAS in recently symptomatic patients. 3 Identifying high-risk patients for whom benefits outweigh risks is crucial. Based on current guidelines, patients are stratified mainly based on the degree of carotid stenosis, but numbers needed to treat (NNTs) are 15 for moderate (50–69%) and 6 for severe (70–99%) stenosis. 4 Additionally, symptomatic patients with mild (30–49%) carotid stenosis are excluded despite a 3% annual stroke risk. 5 Together this indicates that stratification based merely on carotid stenosis leaves substantial room for improvement. While the development of prediction models based on clinical data, such as the CAR score, has improved predictive accuracy compared to grade of stenosis alone, the predictive performance of these models remain insufficient. 6 , 7 Intraplaque hemorrhage (IPH) detected by magnetic resonance imaging (MRI) has emerged as a novel, very strong predictor of recurrent stroke, warranting further investigation into its clinical value. 8 Individualised MRI-based PRediction scOre using plaque Vulnerability for patients with symptomatic carotid artery diseasE (IMPROVE) is a novel clinical decision rule, which is based on a risk score, the IMPROVE clinical prediction model. 9 IMPROVE incorporates IPH, degree of stenosis, age, sex, and classification of last event (cerebral vs ocular), to predict the risk of ipsilateral ischemic stroke recurrence within three years. 9 The IMPROVE prediction model is the first model that incorporates plaque vulnerability to predict ipsilateral ischemic stroke risk on contemporary optimal medical therapy (OMT) with adequate power (≥ 10 events per variable). 9 , 10 Internal validation of the model demonstrated strong predictive performance, with a C-statistic of 0.82. 9 A model-based decision analytic study illustrated the potential benefits of using an IMPROVE-based selection of patients for carotid revascularization, compared to stratification based on current guidelines only. 11 Stratification selection for carotid revascularization of patients with an IMPROVE-calculated 3-year ipsilateral ischemic stroke risk of ≥ 10% led to a 35% reduction in ipsilateral ischemic stroke recurrence within three years, compared to stratification based on current guidelines. 11 This approach also provided a net benefit when considering both costs and perioperative risks. Application of this IMPROVE decision rule in the clinical setting may require additional carotid plaque MR imaging. In approximately half of the patients, MRI is required for the decision rule, while in the other half, it is unnecessary, as the risk of recurrent stroke is already determined to be either very high or low based on the other risk factors. 11 Validation of the IMPROVE decision rule in a randomized controlled trial is necessary to demonstrate the clinical benefits in practice. Yet, it is crucial that the involved clinicians rely on the decision rule in patient management and adhere to its recommendation to authenticate the findings of the decision-analytic study in a clinical trial. Therefore, it is necessary to assess clinicians’ perspective and trust in the IMPROVE decision rule before the start of such a trial. The aim of this study was to assess the acceptability of the IMPROVE decision rule among stroke clinicians in the Netherlands and to identify possible barriers to acceptability. Methods Study population We conducted semi-structured interviews with Dutch clinicians involved in stroke care and stratification for carotid revascularization across 10 clinical centers (5 university and 5 non-university hospitals) in the Netherlands between March 2024 and May 2024. These ten centers were invited to participate to a grant application for a randomized controlled trial to evaluate the IMPROVE decision rule, and all centers demonstrated willingness to participate to the trial, if funded. Clinicians likely to be involved in the trial were identified by the local investigator and proposed as respondents. At each center, at least one (vascular) neurologist and vascular surgeon, and, where feasible, a neuro- or interventional radiologist and a stroke nurse practitioner were invited to participate to an interview to ensure that all relevant specializations were covered. All participants provided consent for their participation in the study and the publication of the results. Data collection All semi-structured interviews were performed by a member of the research team (J.B.). The questionnaire was developed by the research team with backgrounds in neurology (M.T., R.O.), MRI (J.B., M.K.), epidemiology (L.S.), and implementation science (S.A.) (Supplementary Methods). The interviews started with a presentation describing the development of the IMPROVE decision rule and the findings of the decision-analytic study. Interviews were conducted either in person or via video call. All interviews were audiotaped and transcribed verbatim for subsequent analysis. Field notes were recorded following each interview. A member check was conducted by providing each respondent with a summary of their interview for approval, ensuring data accuracy and credibility. Initially, participants were queried regarding their stance on the proposition “the IMPROVE decision rule meets my approval,” which was adapted from the Acceptability of Intervention Measure (AIM). 12 Participants could respond with ‘completely disagree’, ‘disagree’, ‘neither agree nor disagree’, ‘agree’, or ‘completely agree’. Subsequently, participants were asked to specify what would be required for them to 'completely agree' with the AIM proposition. Following this, participants were presented with two clinical cases where discrepancies existed between the current clinical guideline recommendations and those provided by the IMPROVE decision rule. 13 These example cases are detailed in the Supplementary Table 1. Clinicians were queried regarding their adherence to the IMPROVE recommendation within a trial context and the rationale behind their decision-making. Finally, clinicians were queried about potential obstacles expected in implementing this model in clinical practice. Analysis The transcribed interviews were analyzed utilizing NVivo 14 software (Lumivero, Burlington, MA, United States). Data analyses started directly after the interviews using direct content analysis. 14 The responses were systematically coded (J.B.) using a deductive approach according to the eight constructs of the innovation domain in the updated Consolidated Framework for Implementation Research (CFIR), which include: source, evidence-base, relative advantage, adaptability, trialability, complexity, design, and cost. The responses were coded under supervision of an implementation scientist (S.A.). Results We conducted individual interviews of 15 to 30 minutes with 40 clinicians involved in stroke care, consisting of 17 (42.5%) neurologists, 11 (27.5%) vascular surgeons, 9 (22.5%) radiologists, 2 (5%) stroke nurse practitioners and 1 (2.5%) clinical epidemiologist. Further details are provided in Supplementary Table 2. Acceptability of intervention All 40 clinicians responded to the AIM proposition. Twenty-nine clinicians agreed, five clinicians (three neurologists, two radiologists) strongly agreed, and another six clinicians (three neurologists, three vascular surgeons) neither disagreed nor agreed with the AIM proposition that the IMPROVE decision rule met their approval. Barriers to acceptability Our analysis identified 12 barriers for acceptability of the IMPROVE decision rule in four categories of origin: lack of evidence, limited clinical practicality, insufficient familiarity and healthcare burden (Table 1 ). Table 1 Barriers to acceptability categorized by origin of barrier and sorted by frequency. Origin Barrier of acceptability CFIR construct Lack of evidence The benefits have not been demonstrated in a clinical trial. N, VS, R Evidence-base IMPROVE has not been validated in an external validation. N, R Evidence-base Lack of clarity about the details of the development of IMPROVE or decisionanalytic study. N, VS Evidence-base Potential stroke risk predictors are not included in IMPROVE. N, VS Evidence-base The assumptions of routine practice are not representative for our center. N Evidence-base Limited clinical practicality Performing the MRI within time for decision-making presents logistical challenges. N, R Complexity IMPROVE is not applicable for patients with claustrophobia or contraindications for MRI. N, R Adaptability The detection of IPH depends on the image quality. N, VS, R Complexity Insufficient familiarity Familiarity with current practice makes it daunting to alter treatment. N, VS, R Relative advantage No experience with plaque MR imaging within center. N Complexity Healthcare burden The additional MRI scan and analysis increase the workload of radiologists. R Complexity Revascularization considerations for patients with mild stenosis will require additional multidisciplinary consultations. N Complexity Barriers reported by clinicians from the department of Neurology (N), Vascular Surgery (VS), and Radiology (R). Lack of evidence Two barriers can be ascribed to insufficient empirical validation of the benefits of the IMPROVE decision rule. The first, “The benefits have not been demonstrated in a clinical trial” , highlighted by specialists in neurology, vascular surgery, and radiology, is emphasizing the need for clinical evidence supporting IMPROVE’s effectiveness. < I think it is very important that we conduct a clinical trial. If you are going to introduce a new score, it is also good to see if it actually proves to be effective in practice. Of course, it is still a hypothesis at this point. (Neurologist, N15) > The second barrier, “IMPROVE has not been validated in an external validation” , indicates the need of external validation of the predictive performance in an independent dataset. Another barrier, “The details about the development of IMPROVE and decision-analytic study are not clear ”, arises from clinicians' limited familiarity with IMPROVE and was the main barrier for clinicians that answered the AIM proposition with ‘neither disagree nor agree’. Clinicians indicated that publication of the development of IMPROVE and the decision-analytic study on its clinical impact, together with supplementary presentations would enhance their understanding of the details of the IMPROVE decision rule. < I would actually like to know some more background information about which variables you included in the model. For example, what is the assumed risk of perioperative complications in your study? (Neurologist, N7) > The barrier “Potential stroke risk predictors are not included in IMPROVE” reflects concerns about its comprehensiveness. Clinicians suggested adding variables, such as vascular risk profile or presence of micro-emboli on Transcranial Doppler ultrasound, to enhance predictive accuracy. 15 , 16 Furthermore, clinicians speculated about unidentified plaque or brain features that could improve future stroke prediction. < At this moment, with the current state of technology and knowledge, I think IMPROVE is the best we can get. However, we should keep in mind that in the coming years, there may be new insights about new markers that we do not fully understand yet. We will then have to see how we can incorporate them. (Vascular surgeon, VS4) > Lastly, one neurologist mentioned the barrier “The assumptions of routine practice are not representative for our center” . The assumptions regarding care as usual (CAU) in the decision-analytic study followed the latest guidelines of the European Society for Vascular Surgery (ESVS) 13 , recommending carotid revascularization for all patients with > 50% stenosis. The neurologist still agreed with the AIM proposition and acknowledged the value of a risk model incorporating plaque vulnerability. Limited clinical practicality The second group of barriers pertains to the challenges in implementing the IMPROVE decision rule in a clinical setting. The most cited barrier, “Performing the MRI within time for decision-making presents logistical challenges” , highlights the challenge of conducting an additional MRI within the typical short timespan required for clinical decisions on carotid revascularization. Multidisciplinary consultations involving neurologists, vascular surgeons, and radiologists, occur weekly, leaving less than one week available to schedule the MRI, as carotid revascularization is ideally performed within two weeks after the cerebrovascular ischemic event. 13 None of the centers currently conduct carotid plaque imaging in routine clinical practice. However, all consulted neurologists and radiologists agreed that plaque MR imaging before clinical decision-making is feasible in the context of a trial. < The MRI takes extra time. It's an extra step you have to include before the consultation that can lead to delays, which need to be avoided. (Neurologist, N1) > Another frequent cited barrier was that “IMPROVE is not applicable for patients with claustrophobia or contraindications for MRI”. < MRI will not be available for all patients, and for IPH assessment you need an MRI, so what do we do with the people who are eligible for surgery but cannot undergo an MRI because they have absolute contraindications? (Radiologist, R3) > Lastly, “The detection of IPH depends on the image quality” was a common heard concern of clinicians, expressed by clinicians both acquainted and unacquainted with plaque imaging. < IPH can also be large or small. So the question is whether you might need some kind of cut-off, or central reading, just to name a few options. Also, your sequence can determine how large your contrast-to-noise ratio is. There’s variation in that as well. (Radiologist, R4) > Insufficient familiarity The third group of acceptability barriers reflects the clinicians’ unfamiliarity with IMPROVE. The primary barrier, “Familiarity with current practice makes it daunting to alter treatment” , reflects the novelty of the innovation and the associated resistance to its adoption. < The reason that I am not fully convinced yet is mainly unfamiliarity. I do not use IMPROVE on a daily basis. More familiarity for myself, and a clinical study, would help (Neurologist, N17) > Another barrier related to unacquaintance, “No experience with plaque MR imaging within center” , reflects the limited use of plaque MR imaging in Dutch medical centers, where it is not yet employed for decision-making in carotid revascularization. Healthcare burden The final group of barriers highlights the increased burden on healthcare providers when implementing IMPROVE-based care. One clinician noted the barrier “The additional MRI scan and analysis increase the workload of radiologists”. Although dedicated IPH sequences are short and scoring IPH on carotid MRI is relatively straightforward, the high volume of patients potentially requiring carotid revascularization can place a substantial burden on radiology departments. 17 Another clinician highlighted the barrier “Revascularization considerations for patients with mild stenosis will require additional multidisciplinary consultations”. Under current guidelines, only symptomatic patients with > 50% carotid stenosis are considered for revascularization. However, IMPROVE-based care also includes patients with 30–50% carotid stenosis. If the stroke predictors of the IMPROVE decision rule indicate a ≥ 10% risk for an ipsilateral ischemic stroke within 3 years, these patients are also considered for carotid revascularization. This change can significantly increase the number of cases discussed during consultations. < Currently, we only discuss patients in the multidisciplinary consultation if they have at least 50% stenosis. It will be quite a burden if we also start including patients from 30% stenosis. (Neurologist, N16) > Discussion This qualitative study evaluated the acceptability of IMPROVE to select symptomatic patients with 30–99% carotid stenosis for revascularization by assessing the perspective of stroke clinicians and identifying possible barriers to its acceptance. IMPROVE is the first sufficiently powered model to predict 3-year risk of ipsilateral ischemic stroke by incorporating plaque vulnerability. The IMPROVE decision rule was generally well received by most interviewed clinicians. Twelve barriers to acceptance were identified, categorized into four groups: lack of evidence, limited clinical applicability, insufficient familiarity, and healthcare burden. Addressing the evidence gap requires further studies. A randomized controlled trial comparing IMPROVE-based care with standard care is essential to demonstrate the clinical benefits of IMPROVE and convince stroke clinicians of its value. This need aligns with a recent international expert consensus statement, which highlighted the necessity of clinical studies to validate the use of image-based information as a key parameter for guiding therapeutic decisions. 18 The IMPROVE tool addresses this gap by employing MRI-derived and clinical data for outcome prediction and therapy recommendation. Thus, clinical validation of IMPROVE through a randomized trial is crucial for its successful implementation. 18 , 19 External validation of the model would be beneficial, though this depends on the availability of data from cohort studies that included plaque MR imaging and patients that refrained from carotid revascularization. Such studies are scarce, especially for patients with > 50% and > 70% stenosis, as current guidelines recommend revascularization for these groups. The interviews suggested that some clinicians may have limited knowledge about plaque imaging and IMPROVE. Time constraints limited discussion of the model’s development, and at the time of the interviews, neither the model nor the decision-analytic study had been published. Broader dissemination of evidence on IPH risk and IMPROVE is needed among clinicians. The exclusion of predictors, such as micro-emboli or vascular risk profile, was due to limitations on the number of predictors in model development, adhering to a minimum of 10 events per degree of freedom. 10 Current predictor selection was deliberately decided by medical specialists, prioritizing specific predictors over others. However, future studies can refine the model. Cohort studies incorporating both existing as well as newly identified predictors could support further model improvement. Nonetheless, the current IMPROVE model already demonstrates strong predictive performance. 9 Concerns about clinical applicability need to be assessed in practice. While some patients have MRI contraindications, they account for < 3%, and growing MRI compatibility with cardiac devices further reduces this percentage. 20 – 22 Contrast media allergies are irrelevant, as the required MRI protocol does not necessitate contrast injection. 23 IPH imaging has not yet been integrated in routine clinical practice and requires training of MR technicians and radiologists. Nevertheless, dedicated hyper T1-weighted MRI sequences offer excellent diagnostic performance achievable with both 1.5 T and 3 T MRI systems and standard neurovascular radiofrequency MRI coils. 17 , 23 – 25 Practical evaluation is required to assess the real-world applicability of IMPROVE-based care. A feasibility study would best address the practical challenges and constraints of implementation. Limited familiarity with IMPROVE-based care can be addressed through training, feasibility studies, or clinical trials. Resistance to innovation and reliance on prior knowledge are prevalent challenges in adopting healthcare innovations. 26 – 28 IMPROVE represents a particular challenge as it requires a shift in treatment guidelines, which previously avoided revascularization in mild stenosis patients while strongly recommending it for severe stenosis. 13 The shift away from stenosis is challenging, especially without clinical evidence supporting the benefits of IMPROVE. Therefore, clinical studies are essential to reduce resistance and facilitate the transition towards IMPROVE-based decision-making. Training for MRI technicians and radiologists is crucial, especially in centers unfamiliar with plaque imaging. Centers acquainted with plaque MRI in research can offer support and training to centers that lack the expertise. 29 , 30 The potential increase in healthcare burden from IMPROVE-based care should also be evaluated in practice. Although it may add to clinicians' workload, particularly radiologists, IMPROVE has the potential to reduce recurrent strokes, ultimately lowering the long-term healthcare burden. Limitations Our study involved interviews with 40 clinicians involved in stroke care, representing only a proportion of all the involved clinicians in the Netherlands. Consequently, the results are not fully generalizable to the opinion of Dutch clinicians. However, the final interviews did not reveal any new insights or barriers, suggesting that data saturation was achieved and the likelihood of missing a significant barrier is minimal. The participating clinicians included department chairs and full professors from both academic and general medical centers. Therefore, the obtained perspectives and identified barriers provide a representative view of Dutch clinicians’ attitude towards the IMPROVE decision rule. Another limitation is the limited time clinicians had for interviews, resulting in abbreviated presentations, and omissions regarding the details of IMPROVE. The related studies had not yet been published, which may have led to the identification of the barrier concerning unclear details of IMPROVE. Despite these time constraints, all participants discussed the application of IMPROVE and, responded to the AIM proposition, and identified areas for improvement. Conclusion This study assessed the perspectives of Dutch clinicians involved in stroke care on the acceptability of IMPROVE and identified barriers to its acceptance. The majority of clinicians from all disciplines accepted the tool 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. Declarations All participants provided consent for their participation in the study and the publication of the results. Acknowledgments The authors thank all the IMPROVE investigators for their effort and contributions. Sources of Funding None Disclosures None References Rothwell PM, Eliasziw M, Gutnikov SA et al (2003) Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361:107–116 Brott TG, Hobson RW 2nd, Howard G et al (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. 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Supplementary Files IMPROVEInvestigatorsstudygroup.docx List of IMPROVE investigators in the IMPROVE Investigators study group Supplementarymethods.pdf Cite Share Download PDF Status: Published Journal Publication published 07 Sep, 2025 Read the published version in European Journal of Vascular and Endovascular Surgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5917075\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":409542118,\"identity\":\"bd4c2799-ada1-47c2-823d-e220a85097e4\",\"order_by\":0,\"name\":\"Juul 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Nederkoorn\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Paul\",\"middleName\":\"\",\"lastName\":\"Nederkoorn\",\"suffix\":\"\"},{\"id\":409542123,\"identity\":\"dac8c696-f9a0-46f8-a361-5e88d1f50372\",\"order_by\":5,\"name\":\"Daniel Bos\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Daniel\",\"middleName\":\"\",\"lastName\":\"Bos\",\"suffix\":\"\"},{\"id\":409542124,\"identity\":\"0653b155-0200-4bac-a5c8-6df6e4abe0ac\",\"order_by\":6,\"name\":\"Manuela Joore\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Manuela\",\"middleName\":\"\",\"lastName\":\"Joore\",\"suffix\":\"\"},{\"id\":409542125,\"identity\":\"7dfeb66c-fcf2-4d13-8e41-0ae96e216148\",\"order_by\":7,\"name\":\"Alida Postma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Alida\",\"middleName\":\"\",\"lastName\":\"Postma\",\"suffix\":\"\"},{\"id\":409542126,\"identity\":\"99362b72-270b-45e4-b1a6-20d3cf09e949\",\"order_by\":8,\"name\":\"Eline Kooi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Eline\",\"middleName\":\"\",\"lastName\":\"Kooi\",\"suffix\":\"\"},{\"id\":409542127,\"identity\":\"3120fb5b-ad1b-41d1-aa1c-b0855294c9cc\",\"order_by\":9,\"name\":\"Robert van Oostenbrugge\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Robert\",\"middleName\":\"van\",\"lastName\":\"Oostenbrugge\",\"suffix\":\"\"},{\"id\":409542128,\"identity\":\"413485ae-0109-4160-b64d-7060916164aa\",\"order_by\":10,\"name\":\"Luc Smits\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Luc\",\"middleName\":\"\",\"lastName\":\"Smits\",\"suffix\":\"\"},{\"id\":409542633,\"identity\":\"b6f3d199-eacf-439c-8828-c6488c95314b\",\"order_by\":11,\"name\":\"on behalf of the IMPROVE Investigators\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"on\",\"middleName\":\"behalf of the IMPROVE\",\"lastName\":\"Investigators\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-01-28 08:17:38\",\"currentVersionCode\":1,\"declarations\":{\"humanSubjects\":false,\"vertebrateSubjects\":false,\"conflictsOfInterestStatement\":false,\"humanSubjectEthicalGuidelines\":false,\"humanSubjectConsent\":false,\"humanSubjectClinicalTrial\":false,\"humanSubjectCaseReport\":false,\"vertebrateSubjectEthicalGuidelines\":false},\"doi\":\"10.21203/rs.3.rs-5917075/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5917075/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1016/j.ejvs.2025.08.022\",\"type\":\"published\",\"date\":\"2025-09-08T00:00:00+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":91125835,\"identity\":\"f8b226d1-badf-4c95-891a-2e00eecf669b\",\"added_by\":\"auto\",\"created_at\":\"2025-09-11 21:13:07\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":597187,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5917075/v1/f7c9ad4e-2e15-40cc-bc47-7e660e0db5a6.pdf\"},{\"id\":75388133,\"identity\":\"360df6e9-b05c-4c1f-90c9-7d8bb392f4d9\",\"added_by\":\"auto\",\"created_at\":\"2025-02-04 04:40:12\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":13338,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eList of IMPROVE investigators in the IMPROVE Investigators study group\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"IMPROVEInvestigatorsstudygroup.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5917075/v1/6a1d3a34eb9972f1b0ee6832.docx\"},{\"id\":75388138,\"identity\":\"96a2229d-8f5a-42cf-b187-d8e8937ccef7\",\"added_by\":\"auto\",\"created_at\":\"2025-02-04 04:40:12\",\"extension\":\"pdf\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":701999,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Supplementarymethods.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5917075/v1/59e64ce0b49788702348c6e2.pdf\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003e\\u003cstrong\\u003eIMPROVE Decision Rule for Carotid Revascularization: Clinician Perspectives on Acceptability and Implementation Barriers\\u003c/strong\\u003e\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePrevious research has established that carotid revascularization procedures, carotid endarterectomy (CEA) and carotid artery stenting (CAS), can reduce the risk of recurrent ipsilateral stroke in symptomatic patients with \\u0026ge;\\u0026thinsp;50% carotid stenosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e However, these procedures carry perioperative risks with stroke rates of 4.4% for CEA and 7.2% for CAS in recently symptomatic patients.\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e Identifying high-risk patients for whom benefits outweigh risks is crucial. Based on current guidelines, patients are stratified mainly based on the degree of carotid stenosis, but numbers needed to treat (NNTs) are 15 for moderate (50\\u0026ndash;69%) and 6 for severe (70\\u0026ndash;99%) stenosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e Additionally, symptomatic patients with mild (30\\u0026ndash;49%) carotid stenosis are excluded despite a 3% annual stroke risk.\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Together this indicates that stratification based merely on carotid stenosis leaves substantial room for improvement. While the development of prediction models based on clinical data, such as the CAR score, has improved predictive accuracy compared to grade of stenosis alone, the predictive performance of these models remain insufficient.\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e Intraplaque hemorrhage (IPH) detected by magnetic resonance imaging (MRI) has emerged as a novel, very strong predictor of recurrent stroke, warranting further investigation into its clinical value.\\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIndividualised MRI-based PRediction scOre using plaque Vulnerability for patients with symptomatic carotid artery diseasE (IMPROVE) is a novel clinical decision rule, which is based on a risk score, the IMPROVE clinical prediction model.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e IMPROVE incorporates IPH, degree of stenosis, age, sex, and classification of last event (cerebral vs ocular), to predict the risk of ipsilateral ischemic stroke recurrence within three years.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e The IMPROVE prediction model is the first model that incorporates plaque vulnerability to predict ipsilateral ischemic stroke risk on contemporary optimal medical therapy (OMT) with adequate power (\\u0026ge;\\u0026thinsp;10 events per variable).\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Internal validation of the model demonstrated strong predictive performance, with a C-statistic of 0.82.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eA model-based decision analytic study illustrated the potential benefits of using an IMPROVE-based selection of patients for carotid revascularization, compared to stratification based on current guidelines only.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e Stratification selection for carotid revascularization of patients with an IMPROVE-calculated 3-year ipsilateral ischemic stroke risk of \\u0026ge;\\u0026thinsp;10% led to a 35% reduction in ipsilateral ischemic stroke recurrence within three years, compared to stratification based on current guidelines.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e This approach also provided a net benefit when considering both costs and perioperative risks.\\u003c/p\\u003e \\u003cp\\u003eApplication of this IMPROVE decision rule in the clinical setting may require additional carotid plaque MR imaging. In approximately half of the patients, MRI is required for the decision rule, while in the other half, it is unnecessary, as the risk of recurrent stroke is already determined to be either very high or low based on the other risk factors.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e Validation of the IMPROVE decision rule in a randomized controlled trial is necessary to demonstrate the clinical benefits in practice. Yet, it is crucial that the involved clinicians rely on the decision rule in patient management and adhere to its recommendation to authenticate the findings of the decision-analytic study in a clinical trial. Therefore, it is necessary to assess clinicians\\u0026rsquo; perspective and trust in the IMPROVE decision rule before the start of such a trial.\\u003c/p\\u003e \\u003cp\\u003eThe aim of this study was to assess the acceptability of the IMPROVE decision rule among stroke clinicians in the Netherlands and to identify possible barriers to acceptability.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy population\\u003c/h2\\u003e \\u003cp\\u003e We conducted semi-structured interviews with Dutch clinicians involved in stroke care and stratification for carotid revascularization across 10 clinical centers (5 university and 5 non-university hospitals) in the Netherlands between March 2024 and May 2024. These ten centers were invited to participate to a grant application for a randomized controlled trial to evaluate the IMPROVE decision rule, and all centers demonstrated willingness to participate to the trial, if funded. Clinicians likely to be involved in the trial were identified by the local investigator and proposed as respondents. At each center, at least one (vascular) neurologist and vascular surgeon, and, where feasible, a neuro- or interventional radiologist and a stroke nurse practitioner were invited to participate to an interview to ensure that all relevant specializations were covered. All participants provided consent for their participation in the study and the publication of the results.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eData collection\\u003c/h3\\u003e\\n\\u003cp\\u003eAll semi-structured interviews were performed by a member of the research team (J.B.). The questionnaire was developed by the research team with backgrounds in neurology (M.T., R.O.), MRI (J.B., M.K.), epidemiology (L.S.), and implementation science (S.A.) (Supplementary Methods). The interviews started with a presentation describing the development of the IMPROVE decision rule and the findings of the decision-analytic study. Interviews were conducted either in person or via video call. All interviews were audiotaped and transcribed verbatim for subsequent analysis. Field notes were recorded following each interview. A member check was conducted by providing each respondent with a summary of their interview for approval, ensuring data accuracy and credibility.\\u003c/p\\u003e \\u003cp\\u003eInitially, participants were queried regarding their stance on the proposition \\u0026ldquo;the IMPROVE decision rule meets my approval,\\u0026rdquo; which was adapted from the Acceptability of Intervention Measure (AIM).\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e Participants could respond with \\u0026lsquo;completely disagree\\u0026rsquo;, \\u0026lsquo;disagree\\u0026rsquo;, \\u0026lsquo;neither agree nor disagree\\u0026rsquo;, \\u0026lsquo;agree\\u0026rsquo;, or \\u0026lsquo;completely agree\\u0026rsquo;. Subsequently, participants were asked to specify what would be required for them to 'completely agree' with the AIM proposition. Following this, participants were presented with two clinical cases where discrepancies existed between the current clinical guideline recommendations and those provided by the IMPROVE decision rule.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e These example cases are detailed in the Supplementary Table\\u0026nbsp;1. Clinicians were queried regarding their adherence to the IMPROVE recommendation within a trial context and the rationale behind their decision-making. Finally, clinicians were queried about potential obstacles expected in implementing this model in clinical practice.\\u003c/p\\u003e\\n\\u003ch3\\u003eAnalysis\\u003c/h3\\u003e\\n\\u003cp\\u003eThe transcribed interviews were analyzed utilizing NVivo 14 software (Lumivero, Burlington, MA, United States). Data analyses started directly after the interviews using direct content analysis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e The responses were systematically coded (J.B.) using a deductive approach according to the eight constructs of the innovation domain in the updated Consolidated Framework for Implementation Research (CFIR), which include: source, evidence-base, relative advantage, adaptability, trialability, complexity, design, and cost. The responses were coded under supervision of an implementation scientist (S.A.).\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eWe conducted individual interviews of 15 to 30 minutes with 40 clinicians involved in stroke care, consisting of 17 (42.5%) neurologists, 11 (27.5%) vascular surgeons, 9 (22.5%) radiologists, 2 (5%) stroke nurse practitioners and 1 (2.5%) clinical epidemiologist. Further details are provided in Supplementary Table\\u0026nbsp;2.\\u003c/p\\u003e\\n\\u003ch3\\u003eAcceptability of intervention\\u003c/h3\\u003e\\n\\u003cp\\u003eAll 40 clinicians responded to the AIM proposition. Twenty-nine clinicians agreed, five clinicians (three neurologists, two radiologists) strongly agreed, and another six clinicians (three neurologists, three vascular surgeons) neither disagreed nor agreed with the AIM proposition that the IMPROVE decision rule met their approval.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBarriers to acceptability\\u003c/h2\\u003e \\u003cp\\u003eOur analysis identified 12 barriers for acceptability of the IMPROVE decision rule in four categories of origin: lack of evidence, limited clinical practicality, insufficient familiarity and healthcare burden (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eBarriers to acceptability categorized by origin of barrier and sorted by frequency.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOrigin\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBarrier of acceptability\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCFIR construct\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eLack of evidence\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe benefits have not been demonstrated in a clinical trial.\\u003csup\\u003eN, VS, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence-base\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIMPROVE has not been validated in an external validation.\\u003csup\\u003eN, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence-base\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLack of clarity about the details of the development of IMPROVE or decisionanalytic study.\\u003csup\\u003eN, VS\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence-base\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePotential stroke risk predictors are not included in IMPROVE.\\u003csup\\u003eN, VS\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence-base\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe assumptions of routine practice are not representative for our center.\\u003csup\\u003eN\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence-base\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eLimited clinical practicality\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePerforming the MRI within time for decision-making presents logistical challenges.\\u003csup\\u003eN, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eComplexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIMPROVE is not applicable for patients with claustrophobia or contraindications for MRI.\\u003csup\\u003eN, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAdaptability\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe detection of IPH depends on the image quality.\\u003csup\\u003eN, VS, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eComplexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eInsufficient familiarity\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFamiliarity with current practice makes it daunting to alter treatment.\\u003csup\\u003eN, VS, R\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRelative advantage\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo experience with plaque MR imaging within center.\\u003csup\\u003eN\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eComplexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHealthcare burden\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe additional MRI scan and analysis increase the workload of radiologists.\\u003csup\\u003eR\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eComplexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRevascularization considerations for patients with mild stenosis will require additional multidisciplinary consultations.\\u003csup\\u003eN\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eComplexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003e\\u003cem\\u003eBarriers reported by clinicians from the department of Neurology (N), Vascular Surgery (VS), and Radiology (R).\\u003c/em\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eLack of evidence\\u003c/h3\\u003e\\n\\u003cp\\u003eTwo barriers can be ascribed to insufficient empirical validation of the benefits of the IMPROVE decision rule. The first, \\u003cem\\u003e\\u0026ldquo;The benefits have not been demonstrated in a clinical trial\\u0026rdquo;\\u003c/em\\u003e, highlighted by specialists in neurology, vascular surgery, and radiology, is emphasizing the need for clinical evidence supporting IMPROVE\\u0026rsquo;s effectiveness.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; I think it is very important that we conduct a clinical trial. If you are going to introduce a new score, it is also good to see if it actually proves to be effective in practice. Of course, it is still a hypothesis at this point. (Neurologist, N15) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe second barrier, \\u003cem\\u003e\\u0026ldquo;IMPROVE has not been validated in an external validation\\u0026rdquo;\\u003c/em\\u003e, indicates the need of external validation of the predictive performance in an independent dataset.\\u003c/p\\u003e \\u003cp\\u003eAnother barrier, \\u003cem\\u003e\\u0026ldquo;The details about the development of IMPROVE and decision-analytic study are not clear\\u003c/em\\u003e\\u0026rdquo;, arises from clinicians' limited familiarity with IMPROVE and was the main barrier for clinicians that answered the AIM proposition with \\u0026lsquo;neither disagree nor agree\\u0026rsquo;. Clinicians indicated that publication of the development of IMPROVE and the decision-analytic study on its clinical impact, together with supplementary presentations would enhance their understanding of the details of the IMPROVE decision rule.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; I would actually like to know some more background information about which variables you included in the model. For example, what is the assumed risk of perioperative complications in your study? (Neurologist, N7) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe barrier \\u003cem\\u003e\\u0026ldquo;Potential stroke risk predictors are not included in IMPROVE\\u0026rdquo;\\u003c/em\\u003e reflects concerns about its comprehensiveness. Clinicians suggested adding variables, such as vascular risk profile or presence of micro-emboli on Transcranial Doppler ultrasound, to enhance predictive accuracy.\\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e Furthermore, clinicians speculated about unidentified plaque or brain features that could improve future stroke prediction.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; At this moment, with the current state of technology and knowledge, I think IMPROVE is the best we can get. However, we should keep in mind that in the coming years, there may be new insights about new markers that we do not fully understand yet. We will then have to see how we can incorporate them. (Vascular surgeon, VS4) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eLastly, one neurologist mentioned the barrier \\u003cem\\u003e\\u0026ldquo;The assumptions of routine practice are not representative for our center\\u0026rdquo;\\u003c/em\\u003e. The assumptions regarding care as usual (CAU) in the decision-analytic study followed the latest guidelines of the European Society for Vascular Surgery (ESVS)\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e, recommending carotid revascularization for all patients with \\u0026gt;\\u0026thinsp;50% stenosis. The neurologist still agreed with the AIM proposition and acknowledged the value of a risk model incorporating plaque vulnerability.\\u003c/p\\u003e\\n\\u003ch3\\u003eLimited clinical practicality\\u003c/h3\\u003e\\n\\u003cp\\u003eThe second group of barriers pertains to the challenges in implementing the IMPROVE decision rule in a clinical setting. The most cited barrier, \\u003cem\\u003e\\u0026ldquo;Performing the MRI within time for decision-making presents logistical challenges\\u0026rdquo;\\u003c/em\\u003e, highlights the challenge of conducting an additional MRI within the typical short timespan required for clinical decisions on carotid revascularization. Multidisciplinary consultations involving neurologists, vascular surgeons, and radiologists, occur weekly, leaving less than one week available to schedule the MRI, as carotid revascularization is ideally performed within two weeks after the cerebrovascular ischemic event.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e None of the centers currently conduct carotid plaque imaging in routine clinical practice. However, all consulted neurologists and radiologists agreed that plaque MR imaging before clinical decision-making is feasible in the context of a trial.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; The MRI takes extra time. It's an extra step you have to include before the consultation that can lead to delays, which need to be avoided. (Neurologist, N1) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eAnother frequent cited barrier was that \\u0026ldquo;IMPROVE is not applicable for patients with claustrophobia or contraindications for MRI\\u0026rdquo;.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; MRI will not be available for all patients, and for IPH assessment you need an MRI, so what do we do with the people who are eligible for surgery but cannot undergo an MRI because they have absolute contraindications? (Radiologist, R3) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eLastly, \\u003cem\\u003e\\u0026ldquo;The detection of IPH depends on the image quality\\u0026rdquo;\\u003c/em\\u003e was a common heard concern of clinicians, expressed by clinicians both acquainted and unacquainted with plaque imaging.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; IPH can also be large or small. So the question is whether you might need some kind of cut-off, or central reading, just to name a few options. Also, your sequence can determine how large your contrast-to-noise ratio is. There\\u0026rsquo;s variation in that as well. (Radiologist, R4) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eInsufficient familiarity\\u003c/h2\\u003e \\u003cp\\u003eThe third group of acceptability barriers reflects the clinicians\\u0026rsquo; unfamiliarity with IMPROVE. The primary barrier, \\u003cem\\u003e\\u0026ldquo;Familiarity with current practice makes it daunting to alter treatment\\u0026rdquo;\\u003c/em\\u003e, reflects the novelty of the innovation and the associated resistance to its adoption.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; The reason that I am not fully convinced yet is mainly unfamiliarity. I do not use IMPROVE on a daily basis. More familiarity for myself, and a clinical study, would help (Neurologist, N17) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eAnother barrier related to unacquaintance, \\u003cem\\u003e\\u0026ldquo;No experience with plaque MR imaging within center\\u0026rdquo;\\u003c/em\\u003e, reflects the limited use of plaque MR imaging in Dutch medical centers, where it is not yet employed for decision-making in carotid revascularization.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eHealthcare burden\\u003c/h2\\u003e \\u003cp\\u003eThe final group of barriers highlights the increased burden on healthcare providers when implementing IMPROVE-based care. One clinician noted the barrier \\u003cem\\u003e\\u0026ldquo;The additional MRI scan and analysis increase the workload of radiologists\\u0026rdquo;.\\u003c/em\\u003e Although dedicated IPH sequences are short and scoring IPH on carotid MRI is relatively straightforward, the high volume of patients potentially requiring carotid revascularization can place a substantial burden on radiology departments.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e Another clinician highlighted the barrier \\u003cem\\u003e\\u0026ldquo;Revascularization considerations for patients with mild stenosis will require additional multidisciplinary consultations\\u0026rdquo;.\\u003c/em\\u003e Under current guidelines, only symptomatic patients with \\u0026gt;\\u0026thinsp;50% carotid stenosis are considered for revascularization. However, IMPROVE-based care also includes patients with 30\\u0026ndash;50% carotid stenosis. If the stroke predictors of the IMPROVE decision rule indicate a\\u0026thinsp;\\u0026ge;\\u0026thinsp;10% risk for an ipsilateral ischemic stroke within 3 years, these patients are also considered for carotid revascularization. This change can significantly increase the number of cases discussed during consultations.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026lt; Currently, we only discuss patients in the multidisciplinary consultation if they have at least 50% stenosis. It will be quite a burden if we also start including patients from 30% stenosis. (Neurologist, N16) \\u0026gt;\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis qualitative study evaluated the acceptability of IMPROVE to select symptomatic patients with 30\\u0026ndash;99% carotid stenosis for revascularization by assessing the perspective of stroke clinicians and identifying possible barriers to its acceptance. IMPROVE is the first sufficiently powered model to predict 3-year risk of ipsilateral ischemic stroke by incorporating plaque vulnerability. The IMPROVE decision rule was generally well received by most interviewed clinicians. Twelve barriers to acceptance were identified, categorized into four groups: lack of evidence, limited clinical applicability, insufficient familiarity, and healthcare burden.\\u003c/p\\u003e \\u003cp\\u003eAddressing the evidence gap requires further studies. A randomized controlled trial comparing IMPROVE-based care with standard care is essential to demonstrate the clinical benefits of IMPROVE and convince stroke clinicians of its value. This need aligns with a recent international expert consensus statement, which highlighted the necessity of clinical studies to validate the use of image-based information as a key parameter for guiding therapeutic decisions.\\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e The IMPROVE tool addresses this gap by employing MRI-derived and clinical data for outcome prediction and therapy recommendation. Thus, clinical validation of IMPROVE through a randomized trial is crucial for its successful implementation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e External validation of the model would be beneficial, though this depends on the availability of data from cohort studies that included plaque MR imaging and patients that refrained from carotid revascularization. Such studies are scarce, especially for patients with \\u0026gt;\\u0026thinsp;50% and \\u0026gt;\\u0026thinsp;70% stenosis, as current guidelines recommend revascularization for these groups.\\u003c/p\\u003e \\u003cp\\u003eThe interviews suggested that some clinicians may have limited knowledge about plaque imaging and IMPROVE. Time constraints limited discussion of the model\\u0026rsquo;s development, and at the time of the interviews, neither the model nor the decision-analytic study had been published. Broader dissemination of evidence on IPH risk and IMPROVE is needed among clinicians.\\u003c/p\\u003e \\u003cp\\u003eThe exclusion of predictors, such as micro-emboli or vascular risk profile, was due to limitations on the number of predictors in model development, adhering to a minimum of 10 events per degree of freedom.\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Current predictor selection was deliberately decided by medical specialists, prioritizing specific predictors over others. However, future studies can refine the model. Cohort studies incorporating both existing as well as newly identified predictors could support further model improvement. Nonetheless, the current IMPROVE model already demonstrates strong predictive performance.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eConcerns about clinical applicability need to be assessed in practice. While some patients have MRI contraindications, they account for \\u0026lt;\\u0026thinsp;3%, and growing MRI compatibility with cardiac devices further reduces this percentage.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR21\\\" citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e Contrast media allergies are irrelevant, as the required MRI protocol does not necessitate contrast injection.\\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u003c/sup\\u003e IPH imaging has not yet been integrated in routine clinical practice and requires training of MR technicians and radiologists. Nevertheless, dedicated hyper T1-weighted MRI sequences offer excellent diagnostic performance achievable with both 1.5 T and 3 T MRI systems and standard neurovascular radiofrequency MRI coils.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR24\\\" citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e Practical evaluation is required to assess the real-world applicability of IMPROVE-based care. A feasibility study would best address the practical challenges and constraints of implementation. Limited familiarity with IMPROVE-based care can be addressed through training, feasibility studies, or clinical trials.\\u003c/p\\u003e \\u003cp\\u003eResistance to innovation and reliance on prior knowledge are prevalent challenges in adopting healthcare innovations.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR27\\\" citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e IMPROVE represents a particular challenge as it requires a shift in treatment guidelines, which previously avoided revascularization in mild stenosis patients while strongly recommending it for severe stenosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e The shift away from stenosis is challenging, especially without clinical evidence supporting the benefits of IMPROVE. Therefore, clinical studies are essential to reduce resistance and facilitate the transition towards IMPROVE-based decision-making. Training for MRI technicians and radiologists is crucial, especially in centers unfamiliar with plaque imaging. Centers acquainted with plaque MRI in research can offer support and training to centers that lack the expertise.\\u003csup\\u003e\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eThe potential increase in healthcare burden from IMPROVE-based care should also be evaluated in practice. Although it may add to clinicians' workload, particularly radiologists, IMPROVE has the potential to reduce recurrent strokes, ultimately lowering the long-term healthcare burden.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eOur study involved interviews with 40 clinicians involved in stroke care, representing only a proportion of all the involved clinicians in the Netherlands. Consequently, the results are not fully generalizable to the opinion of Dutch clinicians. However, the final interviews did not reveal any new insights or barriers, suggesting that data saturation was achieved and the likelihood of missing a significant barrier is minimal. The participating clinicians included department chairs and full professors from both academic and general medical centers. Therefore, the obtained perspectives and identified barriers provide a representative view of Dutch clinicians\\u0026rsquo; attitude towards the IMPROVE decision rule.\\u003c/p\\u003e \\u003cp\\u003eAnother limitation is the limited time clinicians had for interviews, resulting in abbreviated presentations, and omissions regarding the details of IMPROVE. The related studies had not yet been published, which may have led to the identification of the barrier concerning unclear details of IMPROVE. Despite these time constraints, all participants discussed the application of IMPROVE and, responded to the AIM proposition, and identified areas for improvement.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study assessed the perspectives of Dutch clinicians involved in stroke care on the acceptability of IMPROVE and identified barriers to its acceptance. The majority of clinicians from all disciplines accepted the tool 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.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eAll participants provided consent for their participation in the study and the publication of the results.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors thank all the IMPROVE investigators for their effort and contributions.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSources of Funding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDisclosures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eRothwell PM, Eliasziw M, Gutnikov SA et al (2003) Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361:107\\u0026ndash;116\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBrott TG, Hobson RW 2nd, Howard G et al (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11\\u0026ndash;23\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMuller MD, Lyrer P, Brown MM, Bonati LH (2020) Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev 2:CD000515\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHertzer NR (2009) Current concepts in the management of carotid stenosis. F1000 Med Rep ; 120090224\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSingh N, Marko M, Ospel JM et al (2020) The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 41:1453\\u0026ndash;1459\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNies KPH, Smits LJM, Kassem M et al (2021) Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis. Front Neurol 12:718438\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRothwell PM, Warlow CP (1999) Prediction of benefit from carotid endarterectomy in individual patients: a risk-modelling study. European Carotid Surgery Trialists' Collaborative Group. Lancet 353:2105\\u0026ndash;2110\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchindler A, Schinner R, Altaf N et al (2020) Prediction of Stroke Risk by Detection of Hemorrhage in Carotid Plaques: Meta-Analysis of Individual Patient Data. JACC Cardiovasc Imaging 13:395\\u0026ndash;406\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNies KP, Smits LJ, van Kuijk SM et al (2024) Individualized MRI-based stroke PRediction scOre using plaque Vulnerability for symptomatic carotid artEry disease patients (IMPROVE). Res Sq 20240816\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoons KG, de Groot JA, Bouwmeester W et al (2014) Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist. PLoS Med 11:e1001744\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNies K, Ramaekers B, Auer D et al (2025) Model-based cost-effectiveness of the IMPROVE score versus care as usual for risk-based selection of symptomatic patients for carotid revascularization. Res Square\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWeiner BJ, Lewis CC, Stanick C et al (2017) Psychometric assessment of three newly developed implementation outcome measures. Implement Sci 12:108\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNaylor R, Rantner B, Ancetti S et al (eds) (2023) 's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. \\u003cem\\u003eEur J Vasc Endovasc Surg\\u003c/em\\u003e ; 65: 7-111. 20220520\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAssarroudi A, Heshmati Nabavi F, Armat MR et al (2018) Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs 23:42\\u0026ndash;55\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArboix A (2015) Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke. World J Clin Cases 3:418\\u0026ndash;429\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBonow RH, Witt CE, Mosher BP et al (2017) Transcranial Doppler Microemboli Monitoring for Stroke Risk Stratification in Blunt Cerebrovascular Injury. Crit Care Med 45:e1011\\u0026ndash;e1017\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eScott McNally J, Yoon HC, Kim SE et al (2015) Carotid MRI Detection of Intraplaque Hemorrhage at 3T and 1.5T. J Neuroimaging 25:390\\u0026ndash;396\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSaba L, Brinjikji W, Spence JD et al (2021) Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement. AJNR Am J Neuroradiol 42:1566\\u0026ndash;1575\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKappen TH, van Klei WA, van Wolfswinkel L et al (2018) Evaluating the impact of prediction models: lessons learned, challenges, and recommendations. Diagn Progn Res 2:11\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBhuva A, Charles-Edwards G, Ashmore J et al (2024) Joint British Society consensus recommendations for magnetic resonance imaging for patients with cardiac implantable electronic devices. Heart 110:e3\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHudson DM, Heales C, Meertens R (2022) Review of claustrophobia incidence in MRI: A service evaluation of current rates across a multi-centre service. Radiography (Lond) 28:780\\u0026ndash;787\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBradshaw PJ, Stobie P, Knuiman MW et al (2014) Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population. Open Heart 1:e000177\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOta H, Yarnykh VL, Ferguson MS et al (2010) Carotid intraplaque hemorrhage imaging at 3.0-T MR imaging: comparison of the diagnostic performance of three T1-weighted sequences. 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Trials 23:606\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003evan Dam-Nolen DHK, Truijman MTB, van der Kolk AG et al (2022) Carotid Plaque Characteristics Predict Recurrent Ischemic Stroke and TIA: The PARISK (Plaque At RISK) Study. JACC Cardiovasc Imaging 15:1715\\u0026ndash;1726\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"Maastricht University\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Carotid artery disease, stroke, MRI, risk stratification, decision rule\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5917075/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5917075/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003eCurrent 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eWe 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eTwenty-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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion: \\u003c/strong\\u003eMost 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.\\u003c/p\\u003e\",\"manuscriptTitle\":\"IMPROVE Decision Rule for Carotid Revascularization: Clinician Perspectives on Acceptability and Implementation Barriers\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-02-04 04:40:08\",\"doi\":\"10.21203/rs.3.rs-5917075/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"f34c8162-cd03-4ec8-9ab6-841e551d5114\",\"owner\":[],\"postedDate\":\"February 4th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[{\"id\":43504084,\"name\":\"Neurology\"}],\"tags\":[],\"updatedAt\":\"2025-09-11T21:12:59+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-5917075\",\"link\":\"https://doi.org/10.1016/j.ejvs.2025.08.022\",\"journal\":{\"identity\":\"european-journal-of-vascular-and-endovascular-surgery\",\"isVorOnly\":true,\"title\":\"European Journal of Vascular and Endovascular Surgery\"},\"publishedOn\":\"2025-09-08 00:00:00\",\"publishedOnDateReadable\":\"September 8th, 2025\"},\"versionCreatedAt\":\"2025-02-04 04:40:08\",\"video\":\"\",\"vorDoi\":\"10.1016/j.ejvs.2025.08.022\",\"vorDoiUrl\":\"https://doi.org/10.1016/j.ejvs.2025.08.022\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5917075\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5917075\",\"identity\":\"rs-5917075\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}