The complexities of acute stroke decision-making

Objective: We hypothesized that low rates of tissue plasminogen activator (tPA) use are only partially explained by medical considerations, and that biases, beliefs, systems, and uncertainty affect acute stroke decision-making.

Methods: We generated a list of factors potentially influential in acute stroke decision-making: uncertainty, patient demographics that may predispose to bias (age, sex, comorbidities), physician experiences and beliefs, and systems factors. An online survey was distributed to neurologists in the province of Ontario, Canada, to assess the influence of these elements. A response rate of 69% was achieved.

Results: Seventy-nine percent (79%) of respondents were less likely to administer IV tPA to patients with dementia, and many were less likely to treat patients from nursing homes, with more severe strokes, or over age 80. All respondents recognized the presence of diagnostic uncertainty, and 87% believed that uncertainty in interpreting advanced imaging affected their use of tPA. The majority of respondents (70%) believed that a large left middle cerebral artery territory stroke was a fate worse than death. Four percent did not believe that IV tPA is an effective treatment for stroke.

Conclusions: This study provides evidence for the presence of uncertainty, beliefs, and biases in acute stroke decision-making. This survey should be considered a preliminary investigation of the multiple factors implicit in IV tPA administration.