Picking the good apples: statistics versus good judgment in choosing stent operators for a multicenter clinical trial

Stroke. 2014 Nov;45(11):3325-9. doi: 10.1161/STROKEAHA.114.006807. Epub 2014 Sep 11.


Background and purpose: The Carotid Revascularization Endarterectomy Versus Stenting Trial was completed with a low stroke and death rate. A lead-in series of patients receiving carotid artery stenting was used to select the physician-operators for the study, where performance was evaluated by complication rates and by peer review of cases. Herein, we assess the potential contribution of statistical evaluation of complication rates.

Methods: The ability to discriminate between stent operators who can successfully meet the published guideline of <3% combined rate of stroke and death is calculated under the binomial distribution, based on a small consecutive case series (n=24 patients).

Results: A criterion of ≤2 stroke or death events among the 24 patients (<8% event rate) was required of operators. Setting such a high criterion, however, ensures an inability to exclude operators who cannot meet the criteria. In fact, if a good operator is defined as having a 2% event rate and a poor operator as a 6% event rate, even a series of 240 patients would (on average) still exclude 5.4% of the good operators and include 4.6% of the poor operators.

Conclusions: The low periprocedural event rates in the trial suggest success in separating skillful operators from less skillful. However, it seems unlikely that statistical assessment of event rates in the lead-in contributed to successful selection, but rather successful selection was more likely because of peer review of subjective and other factors including patient volume and technical approaches.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

Keywords: clinical trial; quality control; stroke.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Cerebral Revascularization / standards
  • Cerebral Revascularization / statistics & numerical data
  • Choice Behavior*
  • Clinical Competence / standards*
  • Clinical Competence / statistics & numerical data
  • Endarterectomy, Carotid / standards*
  • Endarterectomy, Carotid / statistics & numerical data
  • Humans
  • Judgment*
  • Physicians / standards*
  • Physicians / statistics & numerical data
  • Prospective Studies
  • Stents / standards*
  • Stents / statistics & numerical data

Associated data

  • ClinicalTrials.gov/NCT00004732