Development of a computerised decision aid for thrombolysis in acute stroke care

Flynn, Darren; Nesbitt, D; Ford, Gary A.; McMeekin, Peter; Rodgers, Helen; Price, Chris; Kray, Christian; Thomson, Richard

doi:10.1186/s12911-014-0127-1

Cited by 46 publications

(49 citation statements)

References 35 publications

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“…49 This was driven to a large extent by the complexity of the ICD pathway, the multiple clinicians involved, the close involvement of relatives and the widening of this complexity when end-of-life issues emerge. As seen in other preference-sensitive decision-making contexts, such as decision-making about thrombolysis in acute stroke care, 42 patients valued the views and support of expert and trusted clinicians (in this context, heart failure nurses with whom many patients in the current study had developed a close and continuing relationship) and close family members.…”

Section: Interpretation Of Findings In Relation To the Literature On mentioning

confidence: 99%

“…41,42 To date, much of the existing (mostly North American) evidence is concerned with what happens in specialist centres, with little consideration of earlier stages of decision-making, particularly in secondary care for initial referral decisions. Equally, there is little available evidence about how decisions on deactivation are made, but a strong suggestion that these are generally made late, and close to death, without planning in advance.…”

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confidence: 99%

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A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Standing

Exley

Flynn

et al. 2016

Health Serv Deliv Res

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Background Implantable cardioverter defibrillators (ICDs) are recommended for patients at high risk of sudden cardiac death or for survivors of cardiac arrest. All ICDs combine a shock function with a pacing function to treat fast and slow heart rhythms, respectively. The pacing function may be very sophisticated and can provide so-called cardiac resynchronisation therapy for the treatment of heart failure using a pacemaker (cardiac resynchronisation therapy with pacemaker) or combined with an ICD [cardiac resynchronisation therapy with defibrillator (CRT-D)]. Decision-making about these devices involves considering the benefit (averting sudden cardiac death), possible risks (inappropriate shocks and psychological problems) and the potential need for deactivation towards the end of life. Objectives To explore patients’/relatives’ and clinicians’ views/experiences of decision-making about ICD and CRT-D implantation and deactivation, to establish how and when ICD risks, benefits and consequences are communicated to patients, to identify individual and organisational facilitators and barriers to discussions about implantation and deactivation and to determine information and decision-support needs for shared decision-making (SDM). Data sources Observations of clinical encounters, in-depth interviews and interactive group workshops with clinicians, patients and their relatives. Methods Observations of consultations with patients being considered for ICD or CRT-D implantation were undertaken to become familiar with the clinical environment and to optimise the sampling strategy. In-depth interviews were conducted with patients, relatives and clinicians to gain detailed insights into their views and experiences. Data collection and analysis occurred concurrently. Interactive workshops with clinicians and patients/relatives were used to validate our findings and to explore how these could be used to support better SDM. Results We conducted 38 observations of clinical encounters, 80 interviews (44 patients/relatives, seven bereaved relatives and 29 clinicians) and two workshops with 11 clinicians and 11 patients/relatives. Patients had variable knowledge about their conditions, the risk of sudden cardiac death and the clinical rationale for ICDs, which sometimes resulted in confusion about the potential benefits. Clinicians used various metaphors, verbal descriptors and numerical risk methods, including variable disclosure of the potential negative impact of ICDs on body image and the risk of psychological problems, to convey information to patients/relatives. Patients/relatives wanted more information about, and more involvement in, deactivation decisions, and expressed a preference that these decisions be addressed at the time of implantation. There was no consensus among clinicians about the initiation or timing of such discussions, or who should take responsibility for them. Introducing deactivation discussions prior to implantation was thus contentious; however, trigger points for deactivation discussions embedded within the pathway were suggested to ensure timely discussions. Limitations Only two patients who were prospectively considering deactivation and seven bereaved relatives were recruited. The study also lacks the perspectives of primary care clinicians. Conclusions There is discordance between patients and clinicians on information requirements, in particular the potential consequences of implantation on psychological well-being and quality of life in the short and long term (deactivation). There were no agreed points across the care pathway at which to discuss deactivation. Codesigned information tools that present balanced information on the benefits, risks and consequences, and SDM skills training for patients/relative and clinicians, would support better SDM about ICDs. Future work Multifaceted SDM interventions that focus on skills development for SDM combined with decision-support tools are warranted, and there is a potential central role for heart failure nurses and physiologists in supporting and preparing patients/relatives for such discussions. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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Section: Interpretation Of Findings In Relation To the Literature On mentioning

confidence: 99%

mentioning

confidence: 99%

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Standing

Exley

Flynn

et al. 2016

Health Serv Deliv Res

Self Cite

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“…The order of presentation of factors was also informed by work to develop the COMPASS decision support tool. 79 At this point, we also considered the relative frequency of various presentations of acute stroke. It was decided that relatively uncommon complications or patient characteristics (e.g.…”

Section: Box 1 Patient-related Factors That Could Influence Decision-mentioning

confidence: 99%

“…63,125,126 Studies have found that cognitive biases associated with intuitive judgments may be remedied by analytical reasoning. 127,128 Thus, decision support tools that facilitate the mapping and visualisation of risk and benefit 79,129 for individual patients may help to counteract intuitive-based biases or misperceptions, as well as assist in better communicating evidence to patients, family and carers. 130 Training and CPD should emphasise benefit of treating up to the 4.5-hour limit and the importance of treating early and not delaying decision-making, as research illustrates a great proportional benefit with early treatment when there are no contraindications for thrombolysis.…”

Section: Key Learning Points and Implications For Research Training mentioning

confidence: 99%

“…7 We drew on qualitative data collected in a previous research programme examining decision-making in acute stroke 14 and on work to inform the development and testing of a computerised decision support tool for thrombolysis in acute stroke care. 79 This included qualitative interview data on the views and experiences of stroke clinicians about thrombolysis decision-making, ethnographic data collected through non-participant observation of thrombolysis decision-making discussions and data from the usability and feasibility testing of the decision support tool.…”

Section: Stage 1: Exploratory Workmentioning

confidence: 99%

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Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Thomson

Brún

Flynn

et al. 2017

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BackgroundIntravenous 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.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA 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.ResultsA 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).LimitationsWe 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.ConclusionsThere 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 workThe 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.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study

et al. 2022

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Objective Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). Methods We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low‐risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. Results We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow‐up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. Conclusions ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.

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Development of a computerised decision aid for thrombolysis in acute stroke care

Cited by 46 publications

References 35 publications

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study

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