Key result
Environmental challenges and low guideline familiarity drive community hospital barriers to stroke tPA use.
Why the study?
Only 1-3% of ischemic stroke patients receive thrombolytic therapy, and provider barriers to adhering to guidelines recommending tPA delivery in acute stroke are not well known.
Answers are grounded in this paper and cite their sources.
Identifies that systems-level environmental factors, patient delays, and internal clinician familiarity and motivation—rather than disagreement with guidelines—are the primary barriers to administering intravenous tPA for acute ischemic stroke in community hospitals.
BACKGROUND: Only 1-3% of ischemic stroke patients receive thrombolytic therapy. Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known. The main objective of this study was to describe barriers to thrombolytic use in acute stroke care. METHODS: Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist). RESULTS: The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines. CONCLUSIONS: Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful.
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Meurer et al. (2011) studied Acute ischemic stroke (n=169). Qualitative barrier assessment via focus groups and structured interviews (INSTINCT trial baseline assessment phase) was evaluated on Qualitatively-derived external and internal barriers to clinician adherence with guidelines recommending intravenous tissue plasminogen activator (tPA) in acute ischemic stroke. Healthcare providers at 12 community hospitals identified external environmental and patient factors, alongside internal lack of guideline familiarity (9/12 hospitals) and motivation, as top barriers to tPA use.
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