title: How Patient Demographics, Imaging, and Beliefs Influence Tissue-Type Plasminogen Activator Use: A Survey of North American Neurologists.
abstract: Understanding physician decision making is increasingly recognized as an important topic of study, especially in stroke care. We sought to characterize the process of acute stroke decision making among neurologists in the United States and Canada from clinical and epistemological perspectives.
  
  
  
  Using a factorial design online survey, respondents were presented with clinical data to mimic an acute stroke encounter. The history, examination, computed tomographic (CT) scan, CT angiogram, and CT perfusion were presented in sequence, and respondents rated their diagnostic confidence and likelihood of treatment with tissue-type plasminogen activator after each element. Patient age, race, sex, and CT perfusion imaging results were randomized, whereas the rest of the clinical presentation was held constant.
  
  
  
  We collected 715 responses, of which 473 (66%) were complete. Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator rose incrementally as additional clinical data were provided. Diagnostic certainty and treatment likelihood were strongly influenced by the clinical history and the CT scan. Other factors such as physicians' personal beliefs or biases were not influential. Respondents' accuracy in interpreting CT angiographic and CT perfusion images was variable and generally low.
  
  
  
  Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator increase with additional clinical data, with the history being the most important factor for diagnostic and treatment decisions. Respondents had difficulty in interpreting the results of CT perfusion scans although they had little impact on treatment decisions. We did not identify treatment bias based on patient age, race, or sex.
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada. mshamy@toh.on.ca.
authors.forename: Michel C F
authors.initials: MC
authors.lastname: Shamy
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Pugliese
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Karl
authors.initials: K
authors.lastname: Meisel
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Rosendo
authors.initials: R
authors.lastname: Rodriguez
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Anthony S
authors.initials: AS
authors.lastname: Kim
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Frank W
authors.initials: FW
authors.lastname: Stahnisch
authors.affiliation: From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
mesh_terms: D001291:Attitude of Health Personnel; D001921:Brain / Q000000981:diagnostic imaging*; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy*; D000066491:Clinical Decision-Making; D000072226:Computed Tomography Angiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D000072141:Neurologists; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: bias (epidemiology); diagnosis; stroke; therapeutics; tissue-type plasminogen activator