title: Provider perceptions of barriers to the emergency use of tPA for acute ischemic stroke: a qualitative study.
abstract: BACKGROUND
  Only 1-3% of ischemic stroke patients receive thrombolytic therapy. Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known. The main objective of this study was to describe barriers to thrombolytic use in acute stroke care.
  
  
  METHODS
  Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist).
  
  
  RESULTS
  The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines.
  
  
  CONCLUSIONS
  Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful.
authors.affiliation: Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA. wmeurer@med.umich.edu
authors.forename: William J
authors.initials: WJ
authors.lastname: Meurer
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Majersik
authors.forename: Shirley M
authors.initials: SM
authors.lastname: Frederiksen
authors.forename: Allison M
authors.initials: AM
authors.lastname: Kade
authors.forename: Annette M
authors.initials: AM
authors.lastname: Sandretto
authors.forename: Phillip A
authors.initials: PA
authors.lastname: Scott
mesh_terms: D001291:Attitude of Health Personnel; D002545:Brain Ischemia / Q000188:drug therapy*; D004630:Emergencies; D004777:Environment; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D017144:Focus Groups; D019983:Guideline Adherence; D006801:Humans; D009042:Motivation; D010361:Patients; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D020377:Self Efficacy; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator