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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 α = .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: motor (31.7%, standard deviation [SD]: 9.5), language/speech (24.1%, SD: 9.6), other neurological deficits (16.6%, SD: 6.4), premorbid status (12.9%, SD: 6.6), age (10.1%, SD: 6.3), and potential thrombolysis contraindication (4.7%, SD: 4.4).

Conclusion:

In a conjoint analysis, surveyed US physicians in academic practice assigned greater weight to motor and speech/language deficits than other neurological deficits, patient age, relative contraindications to thrombolysis, and premorbid disability when deciding to thrombolyse patients with minor stroke.

Keywords

clinical decision-making acute ischemic stroke minor stroke conjoint analysis

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References

Schwamm

Ali

Reeves

. Temporal trends in patient characteristics and treatment with intravenous thrombolysis among acute ischemic stroke patients at Get With The Guidelines-Stroke hospitals. Circ Cardiovasc Qual Outcomes. 2013;6(5):543–549.

Romano

Smith

Liang

. Outcomes in mild acute ischemic stroke treated with intravenous thrombolysis: a retrospective analysis of the Get With the Guidelines-Stroke registry. JAMA Neurol. 2015;72(4):423–431.

Demaerschalk

Kleindorfer

Adeoye

; American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(2):581–641.

Messe

Khatri

Reeves

. Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry. Neurology. 2016;87(15):1565–1574.

Willey

Khatri

Khoury

. Variability in the use of intravenous thrombolysis for mild stroke: experience across the SPOTRIAS network. J Stroke Cerebrovasc Dis. 2013;22:318–322.

Re-examining Acute Eligibility for Thrombolysis Task Force, Levine

Khatri

; NINDS rt-PA Stroke Trial Investigators. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: part 1: rapidly improving stroke symptoms. Stroke. 2013;44(9):2500–2505.

Khatri

Kleindorfer

Yeatts

. Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials. Stroke. 2010;41(11):2581–2586.

Khatri

Kleindorfer

Devlin

. Alteplase for the Treatment of Acute Ischemic Stroke in Patients with Low NIHSS and Not Clearly-Disabling Deficits: Primary Results of the PRISMS Trial. Los Angeles, California: International Stroke Conference; 2018.

Shamy

Pugliese

Meisel

. How patient demographics, imaging, and beliefs influence tissue-type plasminogen activator use: a survey of North American neurologists. Stroke. 2016;47(8):2051–2057.

10.

Levine

Weingast

Weedon

. To treat or not to treat? Exploring factors influencing intravenous thrombolysis treatment decisions for minor stroke. Stroke. 2018;49:1933–1938.

11.

Bridges

Hauber

Marshall

. Conjoint analysis applications in health – a checklist: a report of the ISPOR good research practices for conjoint analysis task force. Value Health. 2011;14(4):403–413.

12.

Balucani

Bianchi

Feldmann

Weedon

Kolychev

Levine

. To treat or not to treat? Pilot survey for minor and rapidly improving stroke. Stroke. 2015;46(3):874–876.

13.

Thomson

De Brún

Flynn

. Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment. Health Serv Deliv Res. 2017.

14.

Hansen

Ombler

. A new method for scoring additive multi-attribute value models using pairwise rankings of alternatives. J Multi-Criteria Decision Analysis. 2008;15:87–107.

15.

Fischer

Baumgartner

Arnold

. What is a minor stroke? Stroke. 2010;41(4):661–666.

16.

Shamy

Jaigobin

. The complexities of acute stroke decision-making: a survey of neurologists. Neurology. 2013;81(13):1130–1133.

17.

De Los Rios

Kleindorfer

Guzik

; SPOTRIAS Investigators. Intravenous fibrinolysis eligibility: a survey of stroke clinicians’ practice patterns and review of the literature. J Stroke Cerebrovasc Dis. 2014;23(8):2130–2138.

18.

Broderick

Palesch

Janis

; National Institutes of Health StrokeNet I. The National Institutes of Health Strokenet: a user’s guide. Stroke. 2016;47(2):301–303.

19.

Coutts

Dubuc

Mandzia

; TEMPO-1 Investigators. Tenecteplase-tissue-type plasminogen activator evaluation for minor ischemic stroke with proven occlusion. Stroke. 2015;46(3):769–774.

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

Abstract

Introduction:

Methods:

Results:

Conclusion:

Keywords

Get full access to this article

References

Supplementary Material