title: Factors that influence clinicians' decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment.
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.
authors.affiliation: 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Aoife
authors.initials: A
authors.lastname: De Brún
authors.affiliation: 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Darren
authors.initials: D
authors.lastname: Flynn
authors.affiliation: 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Laura
authors.initials: L
authors.lastname: Ternent
authors.affiliation: 2 Northumbria Healthcare NHS Foundation Trust, Ashington, UK.|3 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Price
authors.affiliation: 3 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Rodgers
authors.affiliation: 4 Oxford University Hospitals NHS Trust, Oxford, UK.
authors.forename: Gary A
authors.initials: GA
authors.lastname: Ford
authors.affiliation: 2 Northumbria Healthcare NHS Foundation Trust, Ashington, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Rudd
authors.affiliation: 5 Centre for Health Economics, Monash University, Melbourne, Australia.
authors.forename: Emily
authors.initials: E
authors.lastname: Lancsar
authors.affiliation: 6 The Stroke Association, Gateshead, Newcastle upon Tyne, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Simpson
authors.affiliation: 6 The Stroke Association, Gateshead, Newcastle upon Tyne, UK.
authors.forename: John
authors.initials: J
authors.lastname: Teah
authors.affiliation: 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Richard G
authors.initials: RG
authors.lastname: Thomson
mesh_terms: D061605:Administration, Intravenous; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D000066491:Clinical Decision-Making; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D016896:Treatment Outcome; D035501:Uncertainty
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Discrete choice experiment; acute ischemic stroke; clinical decision-making; intravenous thrombolysis