Clinical Decision-Making for Thrombolysis of Acute Minor Stroke Using Adaptive Conjoint Analysis

Abstract

Introduction: There is practice variability in the treatment of patients with minor ischemic stroke with thrombolysis. We sought to determine which clinical factors physicians prioritize in thrombolysis decision-making for minor stroke using adaptive conjoint analysis. Methods: We conducted our conjoint analysis using the Potentially All Pairwise RanKings of all possible Alternatives methodology via the 1000Minds platform to design an online preference survey and circulated it to US physicians involved in stroke care. We evaluated 6 clinical attributes: language/speech deficits, motor deficits, other neurological deficits, history suggestive of increased risk of complication from thrombolysis, age, and premorbid disability. Survey participants were asked to choose between pairs of treatment scenarios with various clinical attributes; scenarios automatically adapted based on participants' prior responses. Preference weights representing the relative importance of each attribute were compared using unadjusted paired t tests. Statistical significance was set at a ¼ .05. Results: Fifty-four participants completed the survey; 61% were vascular neurologists and 93% worked in academic centers. All neurological deficits were ranked higher than age, premorbid status, or potential contraindications to thrombolysis. Differences between each successive mean preference weight were significant:

Effects of intravenous rtPA in patients with minor stroke

“…), which prevented us from differentiating nondisabling from disabling patients. Third, due to the lack of RCT data clinicians assign greater weight to motor and speech/language deficits than other neurological deficits, patient age, relative contraindications to thrombolysis, and premorbid disability when deciding to thromboses patients with minor stroke [ 25 ]. This may cause bias in the NIHSS score and interfere in the selection of patients for thrombolysis to some extent.…”

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“…Given that this had significant impact on the treatment decision (OR 24.29, 95% confidence interval [CI] 7.13–82.71), this may provide insight into some of the practice variability with this clinical entity. Previous studies of practice variability in the administration of thrombolytics in minor stroke have focused on type of disability and comorbid factors 10 . To our knowledge there is not a significant amount of discussion in the literature about the role that trust of the patient's history plays in diagnostic reasoning and treatment decisions.…”

“…Previous studies of practice variability in the administration of thrombolytics in minor stroke have focused on type of disability and comorbid factors. 10 To our knowledge there is not a significant amount of discussion in the literature about the role that trust of the patient's history plays in diagnostic reasoning and treatment decisions. One possible interpretation of this state of affairs is that it is assumed that the patient's history is taken at face value and that reasoning and decisions follow from this trust.…”

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“…The evaluation component of PHP focused on hepatitis C was conducted using ACA. This methodology is recognised (23)(24)(25)(26) as the most efficient in capturing complex health choices. According to each respondent's answer patterns, the Sawtooth software generates a unique and specific ordering of questions from the 24 PHP considered for the project and their different scale degrees (calculated once we built the model).…”