Identification of barriers to the implementation of evidence-based practice for pre-hospital thrombolysis.

INTRODUCTION: Thrombolysis for patients with an ST elevation myocardial infarction (STEMI) is most effective if given promptly. In remote areas, pre-hospital thrombolysis has been shown to be effective and reduce mortality. However, pre-hospital thrombolysis may offer advantages even in urban areas in terms of reduced 'call to needle' times. General practitioners' attitudes are crucial in the delivery of this service. Differences in perceptions between rural or remote and urban GPs have not been examined previously. The aim of this study was to investigate the attitudes and beliefs of GPs with a view to pre-empting potential barriers to service redesign. METHODS: A questionnaire was sent by email and conventional post to all local GPs (n = 261) located in the study area (Highland Region in the North of Scotland). Data were entered into an Excel spreadsheet for statistical analysis. For the purposes of further analysis the data were divided into three groups: 'urban', 'rural' and 'undefined'. Data were analysed by either unpaired Student's t-test or chi(2) statistic as appropriate, with significance taken at the 5% level. Qualitative responses were grouped following thematic analysis. RESULTS: There was a 49% (n = 127) response. More questionnaires were returned by conventional post than email (106 vs 21, p < 0.0001). There did not appear to be a relationship between confidence in giving pre-hospital thrombolysis and number of years worked as a GP. Rural GPs who had previously administered pre-hospital thrombolysis reported higher confidence compared with GPs who had never given pre-hospital thrombolysis (7.5 +/- 1.7 vs 6.3 +/- 2.0, p = 0.01). Responses to two open questions: 'What do you think are the main factors preventing delivery of pre-hospital thrombolysis?' and 'What more could be done to increase your own willingness to administer pre-hospital thrombolysis?' were classified into four areas: training, experience, organisational and equipment issues. CONCLUSIONS: Several potential barriers to improving the uptake of pre-hospital thrombolysis were highlighted and included training, experience, equipment and organisational factors. Rural GPs were more likely to be confident to give thrombolysis. To implement pre-hospital thrombolysis in areas closer to hospitals may require greater support and training of urban GPs, who reported lower confidence in ECG analysis. Many GPs, while under-confident, reported a desire for further training to improve skills. Other GPs clearly stated that they did not consider emergency treatment of myocardial infarction in terms of thrombolysis as part of their role and that the treatment of acute STEMI in the community should be performed by the ambulance service. This view was held by urban rather than rural GPs. In remote areas it is clear that lack of ambulance crews and poor communication between the ambulance service and GPs leads to instances of 'scoop and run' to hospital, even when the distances are considerable and local GPs have the ability and desire to administer pre-hospital thrombolysis. Clear local clinical care pathways are recommended.

A computerised guidance tree (decision aid) for hypertension, based on decision analysis: development and preliminary evaluation.

This paper discusses the piloting of a computerised decision aid that provides individualised information about hypertension to patients. The program is based on decision analysis, using decision trees as a way of structuring information. It incorporates the Framingham risk equation to assess a users' risk of coronary artery disease, together with a detailed assessment of the patient's current lifestyle and their willingness to change behaviour. Users of the program can decide how much or how little information they access. The program assesses individual's preferences for different treatment outcomes, before providing them with guidance on what might be the best treatment option for them. The program was evaluated by 10 patients with a diagnosis of mild to moderate hypertension and 8 health care professionals. Overall, both health care professionals and patients assessed the program positively. The use of a decision aid based on decision analysis may be a useful way of providing information to patients in order to promote shared decision making.

The development and preliminary evaluation of a decision aid based on decision analysis for two treatment conditions: benign prostatic hyperplasia and hypertension.

This paper discusses the development and evaluation of a computerised decision aid that provides individualised information about Benign Prostatic Hyperplasia (BPH) and Hypertension to patients. The program is based on decision analysis, using decision trees as a way of providing users with information regarding the probability of different outcomes occurring, obtaining an individual evaluation of the different outcomes, before providing guidance on what might be the 'best' option for that patient. It is intended that the program can be used as the basis for helping patients to become more involved in decisions about their medical treatment. Eight health care professionals and 19 patients (9 with BPH and 10 with Hypertension) evaluated the program. Overall it was assessed positively by both health care professionals and patients. However, before it can be integrated into health care practice, the program is to be evaluated further in a randomised trial.