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  • 1
    Online Resource
    Online Resource
    Patient-Centered Decision Support in Acute Ischemic Stroke : Qualitative Study of Patients’ and Providers’ Perspectives
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Circulation: Cardiovascular Quality and Outcomes Vol. 8, No. 6_suppl_3 ( 2015-10)
    Details
    In: Circulation: Cardiovascular Quality and Outcomes, Ovid Technologies (Wolters Kluwer Health), Vol. 8, No. 6_suppl_3 ( 2015-10)
    Abstract: National guidelines endorse recombinant tissue-type plasminogen activator (r-tPA) in eligible patients with acute ischemic stroke to improve patients’ functional recovery. However, 23% to 40% of ideal candidates with acute ischemic stroke for reperfusion are not treated, perhaps because of the difficulty in explaining the benefits and risks of r-tPA within the frenetic pace of emergency department care. To support better knowledge transfer and creation of a shared decision-making tool, we conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering r-tPA treatment. Methods and Results— A multidisciplinary team used qualitative research methods to identify informational needs and strategies for describing the benefits and risks of r-tPA in a clinical setting. Through focus groups (n=10) of stroke survivors (n=39) and caregivers (n=24) and individual interviews with emergency physicians (n=23) and advanced practice nurses (n=20), several themes emerged. Survivors and caregivers preferred a broader definition of a good outcome (independence, rather than no significant disability), simpler graphs as compared with detailed pictographs, and presentation of both population and individualized benefits (framed positively) and risk of receiving r-tPA. Some physicians expressed skepticism with the data and the ability to present risk/benefit information emergently, whereas other physicians and most advanced practice nurses thought such information would improve care. Physicians stressed the importance of presenting the risk of thrombolytic-related intracranial hemorrhage. Conclusions— This study suggests that a positively framed risk–benefit tool with graphical presentations of general and patient-specific risk estimates could support patients and providers in considering r-tPA for acute ischemic stroke. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01864928.
    Type of Medium: Online Resource
    ISSN: 1941-7713 , 1941-7705
    URL: Article
    DOI: 10.1161/CIRCOUTCOMES.115.002003
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
    detail.hit.zdb_id: 2453882-6
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  • 2
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    Abstract TP234: What Stroke Survivors and Families Need to Know For Decision-making During Acute Ischemic Stroke Care - A Qualitative Research Study
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Background: Explaining the benefits and risks of tissue plasminogen activator (tPA) is typically done through hurried verbal explanations in the emergency department, but it may not be understood by patients and caregivers. However, spending more time to explain the risks and benefits may delay the administration of tPA. We sought to develop a decision aid tool to facilitate this communication. Methods: A multidisciplinary research team searched available materials of stroke descriptions intended for a lay audience. The research team and medical illustrator also developed different formats of presenting results from the NINDS tPA trial. We conducted focus groups of stroke survivors and their caregivers at two medical centers to provide feedback on what information should be communicated and how it should be presented. Results: To date, we have convened three focus groups. We have enrolled 12 stroke survivors with a mean age of 54. Two had received tPA. We also enrolled three caregivers with a mean age of 68. Survivors typically did not recall being educated about acute stroke or its treatment during the hospitalization. Participants preferred broadening the definition of a “good” outcome to functional independence (i.e. modified Rankin score of 0-2) over a narrower one of being symptom-free. They also preferred viewing information about the increased chance of a good outcome rather than the decreased chance of a bad outcome such as death. Participants’ opinions sometimes differed from researchers’, such as the choice of colors to depict good outcome or death and the preference of simple bar graphs over pictographs. Conclusions: The different opinions between researchers and patients and caregivers highlight the need to obtain input from all stakeholders in designing effective decision aid tools. Further focus groups are planned to refine the decision-aid tool. We also plan to pilot-test the implementation of this tool in the workflow of managing patients with stroke in the emergency department.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.ATP234
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Abstract 215: Differing Perspectives Between Physicians, Patients And Caregivers On The Value Of An Individualized Estimate Of The Benefits Of Thrombolysis At The Time Of Acute Ischemic Stroke: Designing The Resolve (Rapid Evaluation for Stroke Outcomes using Lytics in Vascular Event) Decision Aid
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Circulation: Cardiovascular Quality and Outcomes Vol. 6, No. suppl_1 ( 2013-05)
    Details
    In: Circulation: Cardiovascular Quality and Outcomes, Ovid Technologies (Wolters Kluwer Health), Vol. 6, No. suppl_1 ( 2013-05)
    Abstract: Background: Explaining the risks and benefits of recombinant tissue plasminogen activator (rt-PA) occurs in a hurried conversation in the emergency department and may not be fully grasped by patients and their caregivers. Risk models describing the heterogeneity of benefits from rt-PA in acute ischemic stroke (AIS) have been created, but are not used in routine clinical practice. To develop a tool (RESOLVE) for modeling each patient’s benefits and risks for rt-PA, we conducted qualitative interviews with survivors, their caregivers and emergency physicians to inform the design and improve usability. Methods: A multidisciplinary research team conducted qualitative research through 10 focus groups of survivors and caregivers. We obtained feedback on their preferred role, desired information and their impressions of alternative formats for presenting risk and benefits. Three emergency physicians from 2 sites have been interviewed (with 〉 15 additional physician interviews being currently conducted, the results of which will supplement these preliminary data at the time of presentation). Results: Survivors and caregivers (63 participants: 39 stroke survivors; 43% male) express a need for more information, including specific risks and benefits to treatment. In general, both groups desired an active role in the acute stroke treatment decision. In contrast, the initial physician interviews indicated a hesitancy to provide NINDS data to patients and caregivers, skepticism of the existing data and cultural barriers to the use of rt-PA in AIS, the latter acquired through residency training or the opinions of their clinical colleagues. The interviewed clinicians, however, felt more positive about using rt-PA when a neurologist was readily available to support the decision. Conclusions: Preliminary findings suggest reluctance by emergency physicians to share data about the benefits of rt-PA to stroke patients and their caregivers, despite the desire of the latter for such information. While the additional planned interviews will be needed to confirm these findings, preliminary insights suggest a compelling need to overcome the reticence of emergency physicians to use clinical data to better engage patients in making a shared decision about rt-PA in AIS.
    Type of Medium: Online Resource
    ISSN: 1941-7713 , 1941-7705
    URL: Article
    DOI: 10.1161/circoutcomes.6.suppl_1.A215
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
    detail.hit.zdb_id: 2453882-6
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  • 4
    Online Resource
    Online Resource
    Abstract 272: Preliminary Data from RESOLVE (Rapid Evaluation for Stroke Outcomes using Lytics in Vascular Events) Study
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation: Cardiovascular Quality and Outcomes Vol. 7, No. suppl_1 ( 2014-07)
    Details
    In: Circulation: Cardiovascular Quality and Outcomes, Ovid Technologies (Wolters Kluwer Health), Vol. 7, No. suppl_1 ( 2014-07)
    Abstract: Background: Communicating the risks and benefits of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischemic stroke (AIS) is complex and often a hurried conversation in the emergency department (ED). Visual decision aids have been shown to be superior to standard treatment decision counseling and useful in emergency decision-making. Current rt-PA tools primarily focus on harmful risks while minimizing the positive benefits of treatment. Despite evidence to support enhancement of patient understanding of rt-PA treatment, use of these materials remains low. This study explored patient and family caregiver (CG) recall of rt-PA information provided, and comprehension of AIS and rt-PA education prior to piloting an enhanced individualized risk and benefit decision tool for rt-PA treatment in the ED. Methods: The goal is to interview 150 consecutive AIS rt-PA eligible patients and their CG to obtain feedback on the type of information (verbal or visual), comprehension and recall of risks and benefits provided in the ED. Currently 20 individuals (stroke patients = 8 and CG =12) at one large metropolitan medical center have completed the study. The participants were 35% (7/20) male; mean age 55.9 years, and 100% (20/20) of the survivors received rt-PA. Findings: All participants (20/20) received information on treatment options for AIS education in the ED. Ninety five percent (19/20) of patients did not recall receiving any visual material used in education of risks and benefits. Most patients (18/20) reported understanding that a stroke was caused by a clot in the brain, however only 30% (6/20) recalled having heard of rt-PA prior to coming to the hospital. Forty-five percent (9/20) of the subjects perceived the descriptions of rt-PA with its risks and benefits as being completely clear whereas 20% (4/20) reported they were not at all clear. Conclusions: Preliminary findings showed that less than half of the patients and CG felt the education was clear. However additional interviews are planned. Preliminary insights suggest an opportunity to use an individualized risk and benefit decision tool to inform and engage patients and CG regarding treatment decisions. We believe this can be accomplished without increasing the door to needle time in administration of rt-PA.
    Type of Medium: Online Resource
    ISSN: 1941-7713 , 1941-7705
    URL: Article
    DOI: 10.1161/circoutcomes.7.suppl_1.272
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 5
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    Abstract 277: Conveying Risks and Benefits of rt-PA: the Eyes Have It
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation: Cardiovascular Quality and Outcomes Vol. 7, No. suppl_1 ( 2014-07)
    Details
    In: Circulation: Cardiovascular Quality and Outcomes, Ovid Technologies (Wolters Kluwer Health), Vol. 7, No. suppl_1 ( 2014-07)
    Abstract: Background: During the early phase of ischemic stroke (IS), thrombolytic (recombinant tissue plasminogen activator; rt-PA) therapy has been shown to effectively reverse symptoms and improve outcomes. However, serious bleeding can occur, which has discouraged both patients and physicians from using rt-PA. The purpose of the overall study is to create a decision-making tool that accurately depicts the risk and benefits of rt-PA in a graphical format that effectively engages physicians, patients and their families. Methods: To better understand the most effective method for presenting the probabilities of outcomes we used eye-tracking technology (Applied Science Laboratories D-6 optics) to assess the manner in which participants studied graphs of varying formats. We recorded which components of the graphs that participants looked at, and how long they looked at these graph components. The graphs were developed from a series of qualitative studies and showed 3 representations rt-PA benefits drawn from the NINDS data: bar; stacked bar; and iconic (person outline figures) graphs. Each presented probabilities for outcomes ranging from little/no disability to severe disability/death and risk of bleeding with or without rt-PA use. Stroke survivors or family members were randomly presented with one of the graphs and asked to imagine they were consulting with a physician about using rt-PA for a family member who had just had a stroke. Comprehension was tested with questions assessing knowledge of the risk and outcome percentages presented in the graphs. Results: Participants (n=12) spent a longer time studying the iconic and bar graphs (mean = 64 seconds and 63 seconds, respectively) than the stacked bar graph (mean = 46 seconds). Study time in different graph regions varied by graph type. Participants spent 16%, 7.5 %, and 1.4 % of their study time looking at the key risk information in the stacked bar, bar, and iconic graphs, respectively. In addition, 4 out of 5 subjects who incorrectly identified the risk of bleeding on the comprehension test had studied the iconic graph. When shown all three formats, participants indicated the iconic graph to be confusing and the stacked bar to be most informative. Conclusions: Our preliminary data suggest that stacked bar graphs facilitate better understanding of the risks and benefits of rt-PA in acute IS. Presenting data in this format could better engage patients and families in making treatment decisions in the setting of IS.
    Type of Medium: Online Resource
    ISSN: 1941-7713 , 1941-7705
    URL: Article
    DOI: 10.1161/circoutcomes.7.suppl_1.277
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 6
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    Abstract TP333: Stroke Survivors And Family Perspectives Of Risk/benefit: Developing Resolve (Rapid Evaluation For Stroke Outcomes using Lytics In Vascular Event)
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Background: Intravenous tissue plasminogen activator (IVtPA) is the only approved treatment for acute ischemic stroke (AIS), but is used in only 4-6% of potentially eligible patients. The risk of hemorrhage is fairly easy to communicate, but the benefits of treatment in reducing disability are difficult to estimate for individual patients. During development of an evidence-based tool to encourage participation of stroke survivors and families in tPA treatment decisions, we conducted qualitative interviews to learn how best to present risk/benefit data. Methods: We conducted 3 focus groups to determine effective strategies for presenting the beneficial outcome (modified Rankin Scale; mRS) and the risk of bleeding. Twelve stroke survivors (mean age = 54; 4 female) and 3 family members (mean age = 68; 3 female) participated at 2 different sites. Results: The majority of survivors do not recall being educated about acute stroke or treatment, though families provide vivid recollection. Four themes emerged as they expressed a need for more information (subject identified by Patient/Caregiver, gender, study number, and site): A ‘good’ outcome is a mRS of 0,1, or 2 - “¼I think that 0-2 is REALLY a good outcome as [I’ve] seen severely disabled patients throughout recovery” (PM04LA). Preferred both overall and personalized outcomes estimates: “Tell me my individual risk and then show me how that compares to the general population. As far as the general population, maybe your risk is higher than others.” (PM07KC). Present risk as ‘positive’ outcomes (e.g. the likelihood of mRS 0-2, rather than 3-6): “’Bad outcome’, I don’t like those words. You’re talking about somebody I love, you know.” (CF10KC). Present both risks and benefits of tPA: “I would be open to take a risk if I thought there would be a good chance of a major improvement” (PM08KC). Conclusions: Stroke survivors and families desire more information at the time of acute stroke and agreed that mRS of 0-2 constitutes a good outcome. They articulated what information would be important for deciding about treatment with IVtPA and this will be used to create a decision aid to deliver individualized risk/benefit estimates in an understandable format that can support communication and shared medical decision-making.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.ATP333
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Online Resource
    Abstract NS19: Exploring Clinician Perspectives of Treating Acute Stroke with Thrombolytic Therapy: Results of a Multi-Center Qualitative Research Study
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. suppl_1 ( 2014-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. suppl_1 ( 2014-02)
    Abstract: Study Objectives: Multiple guidelines endorse recombinant tissue plasminogen activator (rt-PA) in eligible patients with acute ischemic stroke (AIS), but only 4-6% of patients are treated. Clinician doubts about treatment benefits or operational barriers may be among the reasons for not treating potentially eligible patients. Through qualitative interviews, we sought to better understand the issues and perspectives for AIS treatment from Emergency Medicine Physicians (EMP) and Neurology and Emergency based Advanced Practice Nurses (APN) looking for similarities and differences. Methods: A multidisciplinary research team conducted in-depth interviews of 23 EMPs from 11 sites, and 20 APNs from 18 sites across the US. An interview guide was designed to elicit their current experience using rt-PA in AIS, approach to discussing rt-PA with patients and families, and cultural attitudes. Results: EMPs (male = 74%; 12 average years of experience) and APNs (male = 5%; 9.4 average years of experience) described two themes as shared perspectives: Timely Presentation and Neurology Presence were both thought to be important facilitators to receive rt-PA. However, differing perspectives emerged in four themes: Knowledge of Long-term Outcomes; Impression of Data; Communication of Risk and Benefit; and Use of Written/Educational Material (Table). The themes and representative quotes are presented by subject number and years in practice. Conclusions: While common perspectives were described, mainly contrasting beliefs emerged, most of which provide an opportunity to develop future strategies to improve guideline adherence for rt-PA use in AIS for each discipline.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.45.suppl_1.ns19
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
    detail.hit.zdb_id: 1467823-8
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