Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2015

Open Access 01-12-2015 | Research article

Development of a computerised decision aid for thrombolysis in acute stroke care

Authors: Darren Flynn, Daniel J Nesbitt, Gary A Ford, Peter McMeekin, Helen Rodgers, Christopher Price, Christian Kray, Richard G Thomson

Published in: BMC Medical Informatics and Decision Making | Issue 1/2015

Login to get access

Abstract

Background

Thrombolytic treatment for acute ischaemic stroke improves prognosis, although there is a risk of bleeding complications leading to early death/severe disability. Benefit from thrombolysis is time dependent and treatment must be administered within 4.5 hours from onset of symptoms, which presents unique challenges for development of tools to support decision making and patient understanding about treatment. Our aim was to develop a decision aid to support patient-specific clinical decision-making about thrombolysis for acute ischaemic stroke, and clinical communication of personalised information on benefits/risks of thrombolysis by clinicians to patients/relatives.

Methods

Using mixed methods we developed a COMPuterised decision Aid for Stroke thrombolysiS (COMPASS) in an iterative staged process (review of available tools; a decision analytic model; interactive group workshops with clinicians and patients/relatives; and prototype usability testing). We then tested the tool in simulated situations with final testing in real life stroke thrombolysis decisions in hospitals. Clinicians used COMPASS pragmatically in managing acute stroke patients potentially eligible for thrombolysis; their experience was assessed using self-completion forms and interviews. Computer logged data assessed time in use, and utilisation of graphical risk presentations and additional features. Patients’/relatives’ experiences of discussions supported by COMPASS were explored using interviews.

Results

COMPASS expresses predicted outcomes (bleeding complications, death, and extent of disability) with and without thrombolysis, presented numerically (percentages and natural frequencies) and graphically (pictographs, bar graphs and flowcharts). COMPASS was used for 25 patients and no adverse effects of use were reported. Median time in use was 2.8 minutes. Graphical risk presentations were shared with 14 patients/relatives. Clinicians (n = 10) valued the patient-specific predictions of benefit from thrombolysis, and the support of better risk communication with patients/relatives. Patients (n = 2) and relatives (n = 6) reported that graphical risk presentations facilitated understanding of benefits/risks of thrombolysis. Additional features (e.g. dosage calculator) were suggested and subsequently embedded within COMPASS to enhance usability.

Conclusions

Our structured development process led to the development of a gamma prototype computerised decision aid. Initial evaluation has demonstrated reasonable acceptability of COMPASS amongst patients, relatives and clinicians. The impact of COMPASS on clinical outcomes requires wider prospective evaluation in clinical settings.
Appendix
Available only for authorised users
Literature
1.
Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012;379:2364–72.CrossRefPubMedPubMedCentral
2.
Lansberg MG, Albers GW, Wijman CA. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: a review of the risk factors. Cerebrovasc Dis. 2007;24:1–10.CrossRefPubMed
3.
Murtagh MJ, Burges Watson DL, Jenkings KN, Lie ML, Mackintosh JE, Ford GA, et al. Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study. PLoS One. 2012;7(6):e37066. doi: 10.1371/journal.pone.0037066.CrossRefPubMedPubMedCentral
4.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New Engl J of Med. 2008;359:1317–29.CrossRef
5.
Lees KR, Bluhmki E, Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS and EPITHET trials. Lancet. 2010;375:1695–703.CrossRefPubMed
6.
Flynn D, Ford GA, Stobbart L, Rodgers H, Murtagh MJ, Thomson RG. A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tool developers. BMC Health Serv Res. 2013;13(1):225. doi: 10.1186/1472-6963-13-225.CrossRefPubMedPubMedCentral
7.
8.
Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–82.CrossRefPubMed
9.
Lecouturier J, Murtagh MJ, Thomson RG, Ford GA, White M, Eccles M, et al. Response to symptoms of stroke in the UK: a systematic review. BMC Health Serv Res. 2010;10:157. doi: 10.1186/1472-6963-10-157.CrossRefPubMedPubMedCentral
10.
National Audit Office. Progress in improving stroke care: a good practice guide. London: National Audit Office; 2010.
11.
12.
13.
Kwan J, Hand P, Sandercock P. A systematic review of barriers to delivery of thrombolysis for acute stroke. Age Ageing. 2004;33:116–21.CrossRefPubMed
14.
Brown DL, Barsan WG, Lisabeth LD, Gallery ME, Morgenstern LB. Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke. Ann Emerg Med. 2005;46:56–60.CrossRefPubMed
15.
Dirks M, Niessen LW, Koudstaal PJ, Franke CL, van Oostenbrugge RJ, Dippel DW. Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contraindications. An international Delphi study. J Neurol Neurosurg Psychiatry. 2007;78:685–9.CrossRefPubMedPubMedCentral
16.
Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2009;4:CD000213.
17.
Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;10:CD001431. doi: 10.1002/14651858.CD001431.pub3.
18.
Eissa A, Krass I, Bajorek BV. Barriers to the utilization of thrombolysis for acute ischaemic stroke. J Clin Pharm Ther. 2012;37:399–409.CrossRefPubMed
19.
Flynn D, Pierce M, Hess E, Murad MH, Erwin PJ, Montori VM, et al. Engaging patients in healthcare decisions in the emergency department through shared decision making: a systematic review. Acad Emerg Med. 2012;19:959–67.CrossRefPubMed
20.
Mangset M, Berge E, Førde R, Nessa J, Wyller TB. “Two per cent isn’t a lot, but when it comes to death it seems quite a lot anyway”: patients’ perception of risk and willingness to accept risks associated with thrombolytic drug treatment for acute stroke. J Med Ethics. 2009;35:42–6.CrossRefPubMed
21.
Bruins Slot K, Berge E. Thrombolytic treatment for stroke: patient preferences for treatment, information and involvement. J Stroke Cerebrovasc Dis. 2009;18:17–22.CrossRef
22.
Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. Patient preferences for stroke outcomes. Stroke. 1994;25:1721–5.CrossRefPubMed
23.
Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. Brit Med J. 2000;321:694–6.CrossRefPubMedPubMedCentral
24.
Elwyn G, Kreuwel I, Durand MA, Sivell S, Joseph-Williams N, Evans R, et al. How to develop web-based decision support interventions for patients: a process map. Patient Educ Couns. 2011;82:260–5.CrossRefPubMed
25.
McMeekin P, Flynn D, Ford GA, Rodgers H, Gray J, Thomson RG: Development of a decision analytic model to support decision-making and risk communication about thrombolytic treatment. BMC Med Inform Decis Mak 2014 (under review).
26.
Kent D, Selker HP, Ruthazer R, Bluhmki E, Hacke W. The Stroke–Thrombolytic Predictive Instrument: a predictive instrument for intravenous thrombolysis in acute ischemic stroke. Stroke. 2006;37:2957–62.CrossRefPubMed
27.
Uyttenboogaart M, Stewart RE, Vroomen PC, Luijckx GJ, De Keyser J. Utility of the stroke-thrombolytic predictive instrument. J Neurol Neurosurg Psychiatry. 2008;79:1079–81.CrossRefPubMed
28.
McMeekin P, Flynn D, Ford GA, Rodgers H, Thomson RG. Validating the Stroke-Thrombolytic Predictive Instrument in a Population in the United Kingdom. Stroke. 2012;43:3378–81.CrossRefPubMed
29.
Wahlgren N, Ahmed N, Eriksson N, Aichner F, Bluhmki E, Dávalos A, et al. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials safe implementation of thrombolysis in stroke-monitoring study (SITS-MOST). Stroke. 2008;39:3316–22.CrossRefPubMed
30.
Ali M, Bath P, Brady M, Davis S, Diener HC, Donnan G, et al. Development, expansion and use of a stroke clinical trials resource for novel exploratory analyses. Int J Stroke. 2012;7:133–8.CrossRefPubMed
31.
Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, et al. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe implementation of treatments in stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012;43:1524–31.CrossRefPubMed
32.
Cucchiara B, Kasner SE, Tanne D. Factors associated with intracerebral hemorrhage after thrombolytic therapy for ischemic stroke: pooled analysis of placebo data from the Stroke-Acute Ischemic NXY Treatment (SAINT) 1 and SAINT II trials. Stroke. 2009;40:3067–72.CrossRefPubMed
33.
34.
Galitz WO. The essential guide to user interface design: an introduction to GUI design principles and techniques. 3rd ed. Indianapolis, IN: Wiley Publishing Inc; 2007.
35.
Snyder C. Paper prototyping: The fast and easy way to design and refine user interfaces. San Francisco, CA: Morgan Kaufman Publishers; 2003.
36.
Krippendorff K. Content analysis: an introduction to its methodology. 2nd ed. Thousand Oaks, CA: Sage; 2004.
37.
38.
Hawley ST, Zikmund-Fisher BJ, Ubel PA, Jancovic A, Lucas T, Fagerlin A. The impact of the format of graphical presentation on health-related knowledge and treatment choices. Patient Educ Couns. 2008;73:448–55.CrossRefPubMed
39.
Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. Brit Med J. 2010;341:971–3.CrossRef
Metadata
Title
Development of a computerised decision aid for thrombolysis in acute stroke care
Authors
Darren Flynn
Daniel J Nesbitt
Gary A Ford
Peter McMeekin
Helen Rodgers
Christopher Price
Christian Kray
Richard G Thomson
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2015
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/s12911-014-0127-1

Other articles of this Issue 1/2015

BMC Medical Informatics and Decision Making 1/2015 Go to the issue

Research article

Assessing measures of comorbidity and functional status for risk adjustment to compare hospital performance for colorectal cancer surgery: a retrospective data-linkage study

Research article

A clinical decision support tool to screen health records for contraindications to stroke thrombolysis–a pilot study

Research article

Experience of using mHealth to link village doctors with physicians: lessons from Chakaria, Bangladesh

Research article

Usability evaluation and adaptation of the e-health Personal Patient Profile-Prostate decision aid for Spanish-speaking Latino men

Research article

Electronic medical record-based multicondition models to predict the risk of 30 day readmission or death among adult medicine patients: validation and comparison to existing models

Study protocol

The influence of a biopsychosocial educational internet-based intervention on pain, dysfunction, quality of life, and pain cognition in chronic low back pain patients in primary care: a mixed methods approach