Background: Alteplase does not uniformly benefit patients with acute ischemic stroke (AIS). Variable times since symptom onset, age, comorbidities and symptom severity add much uncertainty to physicians’ ability to knowledgeably individualize clinical decision-making. This contributes to the recent controversy regarding ACEP-authored expert guidelines which support presentation of risks and benefits and a process of shared decision-making. We previously developed the RESOLVE decision support tool for generating personalized estimates of the benefits and risk of alteplase and developed implementation strategies for both the Emergency Department (ED) and Telehealth settings. This study was a survey of physicians in rural hospitals within a large stroke network to quantify physician’s satisfaction and confidence in treating AIS after having access to the RESOLVE tool.
Methods: To provide rural ED physicians access to the RESOLVE decision support tool prior to the administration of alteplase for AIS, nurses at a centralized Telehealth system were trained to enter the data elements required to run the RESOLVE model and fax the tool to the rural hospital immediately, while the provider was waiting for a neurologist’s consultation from the comprehensive stroke center. We then conducted semi-structured interviews of rural hospital physicians who used the tool as soon as possible. We interviewed 14/28 physicians at 7 critical access hospitals, 6 rural community hospital and one urban public that used the RESOLVE tool in decision making during a 6 month pilot.
Results: Providers strongly agreed the tool was helpful in discussing potential risks and benefits with the patient or family. Having the knowledge of the individualized patient risk of hemorrhage, and being able to inform the patient/family, was a theme that emerged from qualitative analyses of the interviews.
“Knowing the risk of hemorrhage was only 3% made me more comfortable giving IV tPA” - ED Physician, Critical Access Hospital
“[I] used it to discuss the risk of hemorrhage with the patient/family. That was very helpful.” - ED Physician, Urban Public Hospital
“…used it to discuss the benefits and risks, having it helped me to know what to discuss with the patient/family.” - ED Physician, Rural Community Hospital
Study limitations included the difficulty in interviewing physicians due to 12-hour work shift and those practicing as a locum tenens. Additionally, the timing and fax location was a limitation in some physicians seeing the tool prior to prior to treatment.
Conclusions: The preliminary results showed the rural hospital providers saw value in the RESOLVE tool while discussing the risks and benefits with patient/family. Future strategies would include process changes to expedite the faxing of the RESOLVE tool.