Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment
Background: Intravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect...
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| Format: | Article |
| Language: | English |
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National Institute for Health Research
2017-01-01
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| Series: | Health Services and Delivery Research |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/hsdr05040 |
| _version_ | 1818127182085488640 |
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| author | Richard G Thomson Aoife De Brún Darren Flynn Laura Ternent Christopher I Price Helen Rodgers Gary A Ford Matthew Rudd Emily Lancsar Stephen Simpson John Teah |
| author_facet | Richard G Thomson Aoife De Brún Darren Flynn Laura Ternent Christopher I Price Helen Rodgers Gary A Ford Matthew Rudd Emily Lancsar Stephen Simpson John Teah |
| author_sort | Richard G Thomson |
| collection | DOAJ |
| description | Background: Intravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis. Objectives: To identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis. Methods: A discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted. Results: A total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria). Limitations: We anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis. Conclusions: There was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes. Future work: The nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies. Funding: The National Institute for Health Research Health Services and Delivery Research programme. |
| first_indexed | 2024-12-11T07:13:17Z |
| format | Article |
| id | doaj.art-070860c879f84e4d95a92aba3777d064 |
| institution | Directory Open Access Journal |
| issn | 2050-4349 2050-4357 |
| language | English |
| last_indexed | 2024-12-11T07:13:17Z |
| publishDate | 2017-01-01 |
| publisher | National Institute for Health Research |
| record_format | Article |
| series | Health Services and Delivery Research |
| spelling | doaj.art-070860c879f84e4d95a92aba3777d0642022-12-22T01:16:17ZengNational Institute for Health ResearchHealth Services and Delivery Research2050-43492050-43572017-01-015410.3310/hsdr0504012/5001/45Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experimentRichard G Thomson0Aoife De Brún1Darren Flynn2Laura Ternent3Christopher I Price4Helen Rodgers5Gary A Ford6Matthew Rudd7Emily Lancsar8Stephen Simpson9John Teah10Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UKInstitute of Health and Society, Newcastle University, Newcastle upon Tyne, UKInstitute of Health and Society, Newcastle University, Newcastle upon Tyne, UKInstitute of Health and Society, Newcastle University, Newcastle upon Tyne, UKStroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UKStroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UKOxford University Hospitals NHS Trust, Oxford, UKStroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UKCentre for Health Economics, Monash University, Melbourne, VIC, AustraliaThe Stroke Association, Gateshead, UKThe Stroke Association, Gateshead, UKBackground: Intravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis. Objectives: To identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis. Methods: A discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted. Results: A total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria). Limitations: We anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis. Conclusions: There was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes. Future work: The nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies. Funding: The National Institute for Health Research Health Services and Delivery Research programme.https://doi.org/10.3310/hsdr05040discrete choice experimentintravenous thrombolysisclinical decision-makingacute ischaemic strokedesign processmethodologypatient vignettes |
| spellingShingle | Richard G Thomson Aoife De Brún Darren Flynn Laura Ternent Christopher I Price Helen Rodgers Gary A Ford Matthew Rudd Emily Lancsar Stephen Simpson John Teah Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment Health Services and Delivery Research discrete choice experiment intravenous thrombolysis clinical decision-making acute ischaemic stroke design process methodology patient vignettes |
| title | Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment |
| title_full | Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment |
| title_fullStr | Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment |
| title_full_unstemmed | Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment |
| title_short | Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment |
| title_sort | factors that influence variation in clinical decision making about thrombolysis in the treatment of acute ischaemic stroke results of a discrete choice experiment |
| topic | discrete choice experiment intravenous thrombolysis clinical decision-making acute ischaemic stroke design process methodology patient vignettes |
| url | https://doi.org/10.3310/hsdr05040 |
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