From the University of Calgary (M.C.F.S.); and Division of Neurology (C.S.J.), University Health Network, University of Toronto, Canada.
Neurology. 2013 Sep 24;81(13):1130-3. doi: 10.1212/WNL.0b013e3182a55ec7. Epub 2013 Aug 14.
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.
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.
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.
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.
我们假设组织型纤溶酶原激活剂（tPA）使用率低的原因部分是由于医学因素，而偏见、信念、系统和不确定性也会影响急性脑卒中的决策。
我们列出了可能影响急性脑卒中决策的一系列因素：不确定性、可能导致偏见的患者人口统计学特征（年龄、性别、合并症）、医生的经验和信念，以及系统因素。我们向加拿大安大略省的神经科医生分发了在线调查，以评估这些因素的影响。我们获得了 69%的回应率。
79%的受访者不太可能给痴呆症患者使用静脉注射 tPA，许多人不太可能治疗来自养老院、病情更严重或年龄超过 80 岁的患者。所有受访者都认识到存在诊断不确定性，87%的人认为解读高级影像学检查的不确定性会影响他们使用 tPA。大多数受访者（70%）认为大脑中动脉左侧大面积梗死比死亡更糟糕。有 4%的人不认为静脉注射 tPA 是治疗中风的有效方法。
本研究为急性脑卒中决策中的不确定性、信念和偏见提供了证据。这项调查应被视为对静脉注射 tPA 给药中隐含的多种因素的初步调查。
