Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Which educational messengers do medical students prefer for receiving healthinformation? Development and psychometrics of using health messengers questionnaire

INTRODUCTION

Individuals vary in their selection of health messengers. This research aimed to construct an instrument to measure the preferences of medical students in selecting health messengers and in the next step to validate the aforementioned questionnaire.

METHOD

This research is a descriptive survey with an approach to construct a questionnaire. The statistical population included all students studying at Shiraz University of Medical Sciences in March to June 2022 in the academic year 2021-2022. 500 participants were involved in the study. To determine the types of health messengers and review the texts, a group of 15 primary items consisting of the 6 components of academic sources (2-items), formal news sources (2-items), mass media (3-items), internet search (2-items), social networks and messenger applications (4-items), and informal conversation (2-items) were compiled. A 4-point scale was developed the content validity of which was confirmed using CVI and CVR method and the reliability index was calculated to be 0.818. Factor analysis was also used to determine the construct validity and factor loading of each item.

RESULTS

The research covers university students in different medical fields. Using factor analysis, together with KMO = 0.810 and Bartlett's sphericity index P < 0.0001, saturation and the suitability of the test were confirmed. Students' preferences based on factor load were social media (28.92%), official and unofficial health sources(10.76%), academic sources (9.08%), internet search (8.18%), and mass media (7.13%), respectively. Among social media, Telegram (0.85) had the highest factor load followed by Instagram (0.79), and WhatsApp (0.71).

CONCLUSION

Medical students are always on the move and naturally prioritize mobile-based methods. They prefer messengers that are free from time and space restrictions. The widespread availability of mobile devices and the ability to search for and access information make it easier to test health information. Therefore, in health policy, attention should be paid to the virtual capabilities, especially mobile-based approaches.

Which virtual education methods do e‑students prefer? Design and validation of Virtual Education Preferences Questionnaire (VEPQ)

BACKGROUND

With the prevalence of new technologies and evolving student learning styles, virtual teaching methods have become increasingly popular. As a result, more and more students are opting to learn online. However, one common concern is that they may feel disconnected from their teachers, leading to feelings of loneliness and doubts about the quality of education they are receiving. To address this issue, a study was conducted to gather data on students' preferences for virtual education and to validate a tool for measuring students' preferences for virtual education.

METHODS

The research was conducted in a mixed method with a quantitative-qualitative sequence. A virtual education preferences questionnaire (VEPQ) for students with a total of 17 items was created and validated as part of the qualitative component by looking at the theoretical underpinnings and experts' opinions in the focus group. The scale of the six-point Likert questionnaire was from very high to very low. To validate the tool and determine preferences, exploratory factor analysis was used. A total of 155 samples answered the questions and the data were analyzed using SPSS-24 software.

RESULTS

A total of 155 complete questionnaires were returned; among them, 110 (71%) were filled out by women, 73 (47.1%) by respondents between the ages of 36 and 45, 107 (69%) were already employed in paramedical fields, and 48 (31%) were enrolled in a medical school. The opinions of ten experts were used to confirm the face validity of the questionnaire. With CVI = 0.924 and CVR = 0.805, content validity was verified. Using the internal consistency method of the questions with a Cronbach's alpha coefficient of R = 0.824, the validity of the entire questionnaire was confirmed. Exploratory factor analysis revealed that a total of five components-self-directed projects (29.58%), e-content (13.00%), online presentation (10.97%), face-to-face interactions (9.12%), and text interactions (7.11%) had the highest load, with a total of 69.77% of the structure explaining virtual education preferences. The factor analysis test and the suitability of the sample are both confirmed by the value of KMO = 0.721 and the significance of Pvalue < 0.001.

CONCLUSION

It appears that the highly valid tool developed can be used to ascertain the educational preferences of students. Also, the high factor load of self-directed educational methods and e-content shows that independence and flexibility in time and place are more important for students.

Thrombolysis Outcomes in Acute Ischaemic Stroke Patients with Pre-Existing Cognitive Impairment

BACKGROUND

Thrombolysis treatment for ischaemic stroke in patients with pre-existing disabilities, including cognitive impairment, remains controversial. Previous studies have suggested functional outcomes post-thrombolysis are worse in patients with cognitive impairment. This study aimed to compare and explore factors contributing to thrombolysis outcomes, including haemorrhagic complications, in cognitively and non-cognitively impaired patients with ischaemic stroke.

MATERIALS AND METHODS

A retrospective analysis of 428 ischaemic stroke patients who were thrombolysed between January 2016 and February 2021 was performed. Cognitive impairment was defined as a diagnosis of dementia, mild cognitive impairment, or clinical evidence of the condition. The outcome measures included morbidity (using NIHSS and mRS), haemorrhagic complications, and mortality, and were analysed using multivariable logistic regression models.

RESULTS

The analysis of the cohort revealed that 62 patients were cognitively impaired. When compared to those without cognitive impairment, this group showed worse functional status at discharge (mRS 4 vs. 3, p < 0.001) and a higher probability of dying within 90 days (OR 3.34, 95% CI 1.85-6.01, p < 0.001). A higher risk of a fatal ICH post-thrombolysis was observed in the cognitively impaired patients, and, after controlling for covariates, cognitive impairment remained a significant predictor of a fatal haemorrhage (OR 4.79, 95% CI 1.24-18.45, p = 0.023).

CONCLUSIONS

Cognitively impaired ischaemic stroke patients experience increased morbidity, mortality, and haemorrhagic complications following thrombolytic therapy. However cognitive status is not independently predictive of most outcome measures. Further work is required to elucidate contributing factors to the poor outcomes observed in these patients and help guide thrombolysis decision-making in clinical practice.

A new clinical score to predict the possibility of stroke patients receiving intravenous thrombolysis

BACKGROUND

We aimed to develop and validate a clinical score to identify the factors which contribute to variation in, and influence clinician's decision-making about treating acute ischemic stroke (AIS) patients with Intravenous thrombolysis (IVT).

METHODS

We retrospectively included consecutive AIS patients within 4.5 hours after onset in the emergency department (ED), who were admitted to a comprehensive stroke center in Jiangsu province, China. The patients were randomly divided into derivation (60%) and validation data sets (40%) to develop and validate the clinical score. Multivariable stepwise forward logistic regression was performed to identify the independent predictors of IVT offering in the derivation data.

RESULTS

Out of 526 included patients, 418 patients received thrombolytic therapy. Nine patient factors were associated with the likelihood of thrombolysis (age, time to hospital, National Institute of Health stroke scale (NIHSS) score, great vessel, facial paralysis, dizziness, headache, history of stroke, and neutrophil ratio). The c-statistics of the Intravenous Thrombolysis Score in the derivation cohort (n= 316) and validation cohort(n = 210) were 0.795 and 0.751, respectively. The performance of the scoring model was validated with a calibration plot showing good predictive accuracy for the scores in the derivation data (calibrated P = 0.861) and validation data (calibrated P = 0.876).

CONCLUSIONS

The Intravenous Thrombolysis Score for predicting the possibility of offering IVT to AIS patients indicates that clinicians differ in their thresholds for the treatment across a number of patient-related factors, which will be linked to training professional development programmes and address the impact of non-medical influences on decision-making using evidence-based strategies.

Bedaquiline resistance probability to guide treatment decision making for rifampicin-resistant tuberculosis: insights from a qualitative study

BACKGROUND

Bedaquiline (BDQ) is a core drug for rifampicin-resistant tuberculosis (RR-TB) treatment. Accurate prediction of a BDQ-resistant phenotype from genomic data is not yet possible. A Bayesian method to predict BDQ resistance probability from next-generation sequencing data has been proposed as an alternative.

METHODS

We performed a qualitative study to investigate the decision-making of physicians when facing different levels of BDQ resistance probability. Fourteen semi-structured interviews were conducted with physicians experienced in treating RR-TB, sampled purposefully from eight countries with varying income levels and burden of RR-TB. Five simulated patient scenarios were used as a trigger for discussion. Factors influencing the decision of physicians to prescribe BDQ at macro-, meso- and micro levels were explored using thematic analysis.

RESULTS

The perception and interpretation of BDQ resistance probability values varied widely between physicians. The limited availability of other RR-TB drugs and the high cost of BDQ hindered physicians from altering the BDQ-containing regimen and incorporating BDQ resistance probability in their decision-making. The little experience with BDQ susceptibility testing and whole-genome sequencing results, and the discordance between phenotypic susceptibility and resistance probability were other barriers for physicians to interpret the resistance probability estimates. Especially for BDQ resistance probabilities between 25% and 70%, physicians interpreted the resistance probability value dynamically, and other factors such as clinical and bacteriological treatment response, history of exposure to BDQ, and resistance profile were often considered more important than the BDQ probability value for the decision to continue or stop BDQ. In this grey zone, some physicians opted to continue BDQ but added other drugs to strengthen the regimen.

CONCLUSIONS

This study highlights the complexity of physicians' decision-making regarding the use of BDQ in RR-TB regimens for different levels of BDQ resistance probability.. Ensuring sufficient access to BDQ and companion drugs, improving knowledge of the genotype-phenotype association for BDQ resistance, availability of a rapid molecular test, building next-generation sequencing capacity, and developing a clinical decision support system incorporating BDQ resistance probability will all be essential to facilitate the implementation of BDQ resistance probability in personalizing treatment for patients with RR-TB.