Abstract
Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.
Highlights
Stroke remains a leading cause of death and disability.[1]
Earlier treatment is associated with better outcomes, yet there is a small but significant risk of adverse outcomes, mainly due to treatment-related symptomatic intracranial hemorrhage.[9]
Based on data from the Sentinel Stroke National Audit Programme (SSNAP) acute organisation audit,[23] the profile of the current sample in terms of medical specialty is proportionately representative of those involved in decision-making about treatment of acute stroke patients; stroke physicians are most often on thrombolysis rotas, followed in decreasing order by geriatricians, neurologists, accident and emergency (A&E) and acute medicine physicians
Summary
Stroke remains a leading cause of death and disability.[1]. Thrombolysis with recombinant tissue plasminogen activator (intravenous (IV) alteplase) is a cost-effective treatment for acute ischemic stroke that reduces strokerelated disability, but unwarranted variation exists in UK thrombolysis rates[2] despite a strong evidence base[3,4] reflected in the National Stroke Strategy,[5]International Journal of Stroke, 13(1) Brun et al.National Institute for Health and Care Excellence (NICE) guidelines,[6] and treatment licensing criteria.[7]. The study aimed to elucidate patient and clinician factors that influence clinicians’ decision-making about the offer of IV alteplase to patients with acute ischemic stroke. The time limited window for treatment (maximum 4.5 h since symptom onset) and the many clinical factors that might influence the balance between the risk and benefit for individual patients factor into this high stakes decision.[8] Earlier treatment is associated with better outcomes, yet there is a small but significant risk of adverse outcomes, mainly due to treatment-related symptomatic intracranial hemorrhage (sICH).[9] Decision-making is further complicated by uncertainty in research evidence, typically where high-quality data from randomized controlled trials do not exist regarding the suitability of certain patients for treatment with IV alteplase.[10]. This study sought to elucidate factors influencing variation in clinicians’ decision-making about this thrombolytic treatment
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