Information provision and decision-making in the treatment of abdominal aortic aneurysm: A qualitative study of patient experience.

INTRODUCTION: Shared decision making (SDM) refers to patients and health care professionals working together to reach a decision about treatment/care. In abdominal aortic aneurysm (AAA) treatment options are influenced by patients' clinical characteristics, their preferences, and potential trade-offs between alternative interventions. This is a prime example of where SDM is essential to ensure the right decision is made for the right patient, yet we have little understanding of what happens in practice. This study explored patient experiences to understand SDM practice in AAA surgery. METHODS: We used a qualitative approach to describe, and identify improvements to, current treatment decision making in abdominal aortic aneurysm (AAA) surgery. Two groups of patients were interviewed: those at the point of discussing treatment options (with corresponding digitally recorded consultation data) and following surgical intervention from one hospital. Framework analysis was used. RESULTS: Fifteen patients were interviewed, seven at the point of discussing treatment options and eight following surgical intervention. Timing, format and sources of information, verbal framing of interventions and level of patient engagement were key themes. Four areas for improvement were identified: earlier provision and more detailed written information along with signposting to quality on-line information; both intervention options, risks, benefits, and consequences, were not always discussed; some clinicians were somewhat directive in the decision-making process; and patients' treatment values/preferences were not explored-the only example was in one of the eight recorded consultations. Patients could feel overwhelmed by the information and decision and fearful of the impending surgery. CONCLUSIONS: More emphasis should be placed on the provision of full information and the exploration of patient values and preferences for treatment. Clinician training and support for patients, including decision aids, could facilitate the decision-making process. Providing written information earlier and guidance on reliable on-line resources would benefits patients and their families.

Inclusion of person-centred care in UK postgraduate medical education curricula: Interviews and documentary analysis.

BACKGROUND: Person-centred care (PCC) involves placing people at the centre of their healthcare decision making to ensure it meets their needs, values, and personal circumstances. Increasingly, PCC is promoted in healthcare policy and guidance, but little is known about how this is embedded in postgraduate medical training. The aim of this research was to understand how PCC is embedded in UK postgraduate medical training and explore factors influencing inclusion of PCC in curricula content. METHODS: To explore this, we interviewed senior professionals with key roles in the curricula from four UK Royal Colleges (Psychiatrists; Physicians; Surgeons; and GPs) and used framework analysis on interviews and relevant curricula documents to identify themes. RESULTS: Legislation and professional/educational guidance influenced inclusion. PCC definitions and terminology differed and placement within curricula was variable. Royal Colleges defined the curriculum and provided training to ensure competence, but local deaneries independently implemented the curriculum. Trainer engagement was greater than trainee buy in. Quality assurance focused on feedback from trainers and trainees rather than patients, and patient and public involvement in curriculum development, teaching, and assessment was limited. CONCLUSIONS: There is a need for cross-organisation collaboration to develop a PCC competence framework that defines the skills and level of competence required at different points in training, with clarity around the differences between undergraduate and postgraduate requirements. Greater auditing and quality assurance of programme delivery would help identify successful practices to share within and across Royal Colleges, while still maintaining the flexibility of local provision. Engagement with patients and the public in this work can only strengthen provision.

'You can't start a car when there's no petrol left': a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation.

OBJECTIVE: To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians. DESIGN: A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach. SETTING: One tertiary and two district general hospitals in England. PARTICIPANTS: We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals. RESULTS: Four key themes were identified from the data: the current status of deactivation discussions; patients' perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided. CONCLUSIONS: There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life.

Inclusion of person-centred care in medical and nursing undergraduate curricula in the UK: Interviews and documentary analysis.

OBJECTIVE: We aimed to understand how person-centred care (PCC) is represented in UK professional standards for undergraduate medical/nursing education and explored how these are reflected in programme provision. METHODS: We identified PCC components in medical (GMC) and nursing (NMC) professional standards and university curricula documents provided. We also identified themes from interviews with high-level informants for medical/nursing undergraduate programmes using framework analysis. RESULTS: The GMC appears to promote a more paternalistic model of care with discrete PCC components in specific sections and the NMC a more collaborative model with PCC distributed throughout. These differences persisted into education delivery. Medical educators perceived greater barriers to inclusion of PCC than nursing educators; however, both consistently identified cultural and organisational attributes. Clarity was lacking regarding PCC definition, how to teach/assess PCC, and competence expectations. CONCLUSION: Development of a PCC skills competence framework would increase consistency and support teaching and assessment in undergraduate curricula. Further research to understand the perspectives of healthcare professionals involved in placements would help inform PCC teaching recommendations. PRACTICE IMPLICATIONS: High-level support from senior HEI leaders; multi-disciplinary approaches to curricula development, teaching, and assessment; and greater inclusion of service users would ensure higher quality PCC education for undergraduate students.

The Recognition-Response Gap in Acute Stroke: Examining the Relationship between Stroke Recognition and Response in a General Population Survey.

BACKGROUND: Benefits of reperfusion therapies in acute ischemic stroke are highly time-dependent. It is crucial that people who witness the onset of symptoms call emergency medical services (EMS) immediately. The aim of this study was to examine whether there is a gap between recognition of stroke and responding correctly by calling EMS using a scenario-based measure. METHODS: Population-based survey of 1406 individuals from Newcastle upon Tyne, UK, examining stroke recognition and response knowledge using 12 scenario-based vignettes. The response rate was 32% out of 5000 contacted individuals. In total, 16,574 responses to scenarios were examined to investigate whether respondents would recognise stroke symptoms and indicate to call EMS immediately. RESULTS: In 16% of cases people recognised stroke but did not correctly respond by indicating to call EMS. In 49% of responses people recognised stroke and would respond correctly, while in 31% of cases people both failed to correctly recognise and failed to identify the correct response to the stroke scenario. In 5% of cases stroke was not identified but a correct response was indicated. When stroke was recognised, in 25% of responses people indicated that they would not call EMS. Recognition self-efficacy and response self-efficacy were associated with correct response. CONCLUSIONS: A recognition-response gap was identified among UK adults in hypothetical scenarios concerning stroke. Both recognition and translation to adequate EMS response should be explicitly addressed in interventions aiming to improve witness response to stroke. Self-efficacy may be a promising target to close the recognition-response gap.

A novel design process for selection of attributes for inclusion in discrete choice experiments: case study exploring variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke.

BACKGROUND: A discrete choice experiment (DCE) is a method used to elicit participants' preferences and the relative importance of different attributes and levels within a decision-making process. DCEs have become popular in healthcare; however, approaches to identify the attributes/levels influencing a decision of interest and to selection methods for their inclusion in a DCE are under-reported. Our objectives were: to explore the development process used to select/present attributes/levels from the identified range that may be influential; to describe a systematic and rigorous development process for design of a DCE in the context of thrombolytic therapy for acute stroke; and, to discuss the advantages of our five-stage approach to enhance current guidance for developing DCEs. METHODS: A five-stage DCE development process was undertaken. Methods employed included literature review, qualitative analysis of interview and ethnographic data, expert panel discussions, a quantitative structured prioritisation (ranking) exercise and pilot testing of the DCE using a 'think aloud' approach. RESULTS: The five-stage process reported helped to reduce the list of 22 initial patient-related factors to a final set of nine variable factors and six fixed factors for inclusion in a testable DCE using a vignette model of presentation. CONCLUSIONS: In order for the data and conclusions generated by DCEs to be deemed valid, it is crucial that the methods of design and development are documented and reported. This paper has detailed a rigorous and systematic approach to DCE development which may be useful to researchers seeking to establish methods for reducing and prioritising attributes for inclusion in future DCEs.

Factors that influence clinicians' decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment.

Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.

Quality of reporting of patient decision aids in recent randomized controlled trials: A descriptive synthesis and comparative analysis.

OBJECTIVE: Variable reporting of patient decision aids (PDAs) in published articles raises uncertainty about whether the intervention meets the definition of a PDA. We appraised the quality of reporting of PDA characteristics in randomized controlled trials (RCTs). METHODS: RCTs eligible for the Cochrane review of PDAs and published June 2012 to April 2015 were included. Quality of PDA reporting was appraised using the International Patient Decision Aid Standards Instrument (v4.0). We descriptively synthesized and comparatively analysed qualifying and certification criteria reported in each publication against their presence in actual PDAs. RESULTS: Seventeen RCTs evaluating sixteen PDAs were included. Ten PDAs (58.8%) were reported using all qualifying criteria. Two (11.8%) were reported using all certification criteria. The median score for reporting qualifying criteria was 6 of 6 (range 4-6). The median score for reporting certification criteria was 2 of 10 (range 2-3) for screening and 1 of 6 (range 0-6) for treatment decisions. CONCLUSION: Reporting of PDAs in RCTs is suboptimal. Incomplete reporting poses challenges for clinicians and researchers needing to identify PDA content for clinical practice and/or future research. PRACTICE IMPLICATIONS: Authors should report IPDASi (v4.0) criteria in published articles. Reporting guidelines for PDA evaluation studies are in development to improve reporting within the scientific literature.

Can we routinely measure patient involvement in treatment decision-making in chronic kidney care? A service evaluation in 27 renal units in the UK.

BACKGROUND: Shared decision making is considered an important aspect of chronic disease management. We explored the feasibility of routinely measuring kidney patients' involvement in making decisions about renal replacement therapy (RRT) in National Health Service settings. METHODS: We disseminated a 17-item paper questionnaire on involvement in decision-making among adult patients with established kidney failure who made a decision about RRT in the previous 90 days (Phase 1) and patients who had been receiving RRT for 90-180 days (Phase 2). Recruitment rates were calculated as the ratio between the number of included and expected eligible patients (I : E ratio). We assessed our sample's representativeness by comparing demographics between participants and incident patients in the UK Renal Registry. RESULTS: Three hundred and five (Phase 1) and 187 (Phase 2) patients were included. For Phase 1, the I : E ratio was 0.44 (range, 0.08-2.80) compared with 0.27 (range, 0.04-1.05) in Phase 2. Study participants were more likely to be white compared with incident RRT patients (88 versus 77%; P < 0.0001). We found no difference in age, gender or social deprivation. In Phases 1 and 2, the majority reported a collaborative decision-making style (73 and 69%), and had no decisional conflict (85 and 76%); the median score for shared decision-making experience was 12.5 (Phase 1) and 10 (Phase 2) out of 20. CONCLUSION: Our study shows the importance of assessing the feasibility of data collection in a chronic disease context prior to implementation in routine practice. Routine measurement of patient involvement in established kidney disease treatment decisions is feasible, but there are challenges in selecting the measure needed to capture experience of involvement, reducing variation in response rate by service and identifying when to capture experience in a service managing people's chronic disease over time.

Development of a decision analytic model to support decision making and risk communication about thrombolytic treatment.

BACKGROUND: Individualised prediction of outcomes can support clinical and shared decision making. This paper describes the building of such a model to predict outcomes with and without intravenous thrombolysis treatment following ischaemic stroke. METHODS: A decision analytic model (DAM) was constructed to establish the likely balance of benefits and risks of treating acute ischaemic stroke with thrombolysis. Probability of independence, (modified Rankin score mRS ≤ 2), dependence (mRS 3 to 5) and death at three months post-stroke was based on a calibrated version of the Stroke-Thrombolytic Predictive Instrument using data from routinely treated stroke patients in the Safe Implementation of Treatments in Stroke (SITS-UK) registry. Predictions in untreated patients were validated using data from the Virtual International Stroke Trials Archive (VISTA). The probability of symptomatic intracerebral haemorrhage in treated patients was incorporated using a scoring model from Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) data. RESULTS: The model predicts probabilities of haemorrhage, death, independence and dependence at 3-months, with and without thrombolysis, as a function of 13 patient characteristics. Calibration (and inclusion of additional predictors) of the Stroke-Thrombolytic Predictive Instrument (S-TPI) addressed issues of under and over prediction. Validation with VISTA data confirmed that assumptions about treatment effect were just. The C-statistics for independence and death in treated patients in the DAM were 0.793 and 0.771 respectively, and 0.776 for independence in untreated patients from VISTA. CONCLUSIONS: We have produced a DAM that provides an estimation of the likely benefits and risks of thrombolysis for individual patients, which has subsequently been embedded in a computerised decision aid to support better decision-making and informed consent.

Patients or volunteers? The impact of motivation for trial participation on the efficacy of patient decision Aids: a secondary analysis of a Cochrane systematic review.

BACKGROUND: Efficacy of patient decision aids (PtDAs) may be influenced by trial participants' identity either as patients seeking to benefit personally from involvement or as volunteers supporting the research effort. AIM: To determine if study characteristics indicative of participants' trial identity might influence PtDA efficacy. METHODS: We undertook exploratory subgroup meta-analysis of the 2011 Cochrane review of PtDAs, including trials that compared PtDA with usual care for treatment decisions. We extracted data on whether participants initiated the care pathway, setting, practitioner interactions, and 6 outcome variables (knowledge, risk perception, decisional conflict, feeling informed, feeling clear about values, and participation). The main subgroup analysis categorized trials as "volunteerism" or "patienthood" on the basis of whether participants initiated the care pathway. A supplementary subgroup analysis categorized trials on the basis of whether any volunteerism factors were present (participants had not initiated the care pathway, had attended a research setting, or had a face-to-face interaction with a researcher). RESULTS: Twenty-nine trials were included. Compared with volunteerism trials, pooled effect sizes were higher in patienthood trials (where participants initiated the care pathway) for knowledge, decisional conflict, feeling informed, feeling clear, and participation. The subgroup difference was statistically significant for knowledge only (P = 0.03). When trials were compared on the basis of whether volunteerism factors were present, knowledge was significantly greater in patienthood trials (P < 0.001), but there was otherwise no consistent pattern of differences in effects across outcomes. CONCLUSIONS: There is a tendency toward greater PtDA efficacy in trials in which participants initiate the pathway of care. Knowledge acquisition appears to be greater in trials where participants are predominantly patients rather than volunteers.

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

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.

A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia.

Evidence of effectiveness of interventions for treatment of childhood intermittent exotropia, X(T), is unclear. We conducted a systematic review to locate, appraise and synthesise evidence of effectiveness, including twelve electronic databases, supplemented with hand searches and expert contact. We included randomised controlled trials, quasi-experimental and cohort studies with a comparison group examining interventions for divergence excess, simulated divergence excess or basic type X(T) in children, up to and including 18 years of age, followed for at least 6 months. Dual data extraction and critical appraisal were conducted and a narrative synthesis undertaken. Eleven studies satisfied the eligibility criteria. Seven examined the comparative effectiveness of two surgical procedures; four compared surgery with other interventions, including botulinum toxin A therapy, orthoptic exercises, occlusion, binocular vision training and watchful waiting. The evidence retrieved was of limited extent and quality with differences across studies in terms of outcome assessment and most appropriate time-point for measuring long-term outcomes. There were mixed outcomes when comparing unilateral recession/resection (R&R) with bilateral lateral rectus recession (BLR) on improving angle of deviation, which makes it difficult to recommend either surgical option with confidence. While non-surgical interventions appear less effective in terms of improving angle of deviation, they are rarely associated with adverse outcomes. Given the limited evidence base, better designed studies are required to address the question of the most effective management for treatment of childhood X(T). Importantly, consensus is required on what constitutes a successful outcome as well as agreement on how this should be measured.

The stroke 'Act FAST' campaign: remembered but not understood?

BACKGROUND: The stroke awareness raising campaign 'Act FAST' (Face, Arms, Speech: Time to call Emergency Medical Services) has been rolled out in multiple waves in England, but impact on stroke recognition and response remains unclear. PURPOSE: The purpose of this study was to test whether providing knowledge of the FAST acronym through a standard Act FAST campaign leaflet increases accurate recognition and response in stroke-based scenario measures. METHODS: This is a population-based, cross-sectional survey of adults in Newcastle upon Tyne, UK, sampled using the electoral register, with individuals randomized to receive a questionnaire and Act FAST leaflet (n = 2500) or a questionnaire only (n = 2500) in 2012. Campaign message retention, stroke recognition, and response measured through 16 scenario-based vignettes were assessed. Data were analyzed in 2013. RESULTS: Questionnaire return rate was 32.3% (n = 1615). No differences were found between the leaflet and no-leaflet groups in return rate or demographics. Participants who received a leaflet showed better campaign recall (75.7% vs. 68.2%, P = 0.003) and recalled more FAST mnemonic elements (66.1% vs. 45.3% elements named correctly, P < 0.001). However, there were no between-group differences for stroke recognition and response to stroke-based scenarios (P > 0.05). CONCLUSIONS: Despite greater levels of recall of specific 'Act FAST' elements among those receiving the Act FAST leaflet, there was no impact on stroke recognition and response measures.

Health state descriptions to elicit stroke values: do they reflect patient experience of stroke?

BACKGROUND: To explore whether stroke health state descriptions used in preference elicitation studies reflect patients' experiences by comparing published descriptions with qualitative studies exploring patients' lived experience. METHODS: Two literature reviews were conducted: on stroke health state descriptions used in direct preference elicitation studies and the qualitative literature on patients' stroke experience. Content and comparative thematic analysis was used to identify characteristics of stroke experience in both types of study which were further mapped onto health related quality of life (HRQOL) domains relevant to stroke. Two authors reviewed the coded text, categories and domains. RESULTS: We included 35 studies: seven direct preference elicitation studies and 28 qualitative studies on patients' experience. Fifteen coded categories were identified in the published health state descriptions and 29 in the qualitative studies. When mapped onto domains related to HRQOL, qualitative studies included a wider range of categories in every domain that were relevant to the patients' experience than health state descriptions. CONCLUSIONS: Variation exists in the content of health state descriptions for all levels of stroke severity, most critically with a major disjuncture between the content of descriptions and how stroke is experienced by patients. There is no systematic method for constructing the content/scope of health state descriptions for stroke, and the patient perspective is not incorporated, producing descriptions with major deficits in reflecting the lived experience of stroke, and raising serious questions about the values derived from such descriptions and conclusions based on these values.

A time series evaluation of the FAST National Stroke Awareness Campaign in England.

OBJECTIVE: In February 2009, the Department of Health in England launched the Face, Arm, Speech, and Time (FAST) mass media campaign, to raise public awareness of stroke symptoms and the need for an emergency response. We aimed to evaluate the impact of three consecutive phases of FAST using population-level measures of behaviour in England. METHODS: Interrupted time series (May 2007 to February 2011) assessed the impact of the campaign on: access to a national stroke charity's information resources (Stroke Association [SA]); emergency hospital admissions with a primary diagnosis of stroke (Hospital Episode Statistics for England); and thrombolysis activity from centres in England contributing data to the Safe Implementation of Thrombolysis in Stroke UK database. RESULTS: Before the campaign, emergency admissions (and patients admitted via accident and emergency [A&E]) and thrombolysis activity was increasing significantly over time, whereas emergency admissions via general practitioners (GPs) were decreasing significantly. SA webpage views, calls to their helpline and information materials dispatched increased significantly after phase one. Website hits/views, and information materials dispatched decreased after phase one; these outcomes increased significantly during phases two and three. After phase one there were significant increases in overall emergency admissions (505, 95% CI = 75 to 935) and patients admitted via A&E (451, 95% CI = 26 to 875). Significantly fewer monthly emergency admissions via GPs were reported after phase three (-19, 95% CI =  -29 to -9). Thrombolysis activity per month significantly increased after phases one (3, 95% CI = 1 to 6), and three (3, 95% CI = 1 to 4). CONCLUSIONS: Phase one had a statistically significant impact on information seeking behaviour and emergency admissions, with additional impact that may be attributable to subsequent phases on information seeking behaviour, emergency admissions via GPs, and thrombolysis activity. Future campaigns should be accompanied by evaluation of impact on clinical outcomes such as reduced stroke-related morbidity and mortality.

Understanding clinicians' decisions to offer intravenous thrombolytic treatment to patients with acute ischaemic stroke: a protocol for a discrete choice experiment.

BACKGROUND: Intravenous thrombolysis is an effective emergency treatment for acute ischaemic stroke for patients meeting specific criteria. Approximately 12% of eligible patients in England, Wales and Northern Ireland received thrombolysis in the first quarter of 2013, yet as many as 15% are eligible to receive treatment. Suboptimal use of thrombolysis may have been largely attributable to structural factors; however, with the widespread implementation of 24/7 hyper acute stroke services, continuing variation is likely to reflect differences in clinical decision-making, in particular the influence of ambiguous areas within the guidelines, licensing criteria and research evidence. Clinicians' perceptions about thrombolysis may now exert a greater influence on treatment rates than structural/service factors. This research seeks to elucidate factors influencing thrombolysis decision-making by using patient vignettes to identify (1) patient-related and clinician-related factors that may help to explain variation in treatment and (2) associated trade-offs in decision-making based on the interplay of critical factors. METHODS/ANALYSIS: A discrete choice experiment (DCE) will be conducted to better understand how clinicians make decisions about whether or not to offer thrombolysis to patients with acute ischaemic stroke. To inform the design, exploratory work will be undertaken to ensure that (1) all potentially influential factors are considered for inclusion; and (2) to gain insights into the 'grey areas' of patient factors. A fractional factorial design will be used to combine levels of patient factors in vignettes, which will be presented to clinicians to allow estimation of the variable effects on decisions to offer thrombolysis. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Newcastle University Research Ethics Committee. The results will be disseminated in peer review publications and at national conferences. Findings will be translated into continuing professional development activities and will support implementation of a computerised decision aid for thrombolysis (COMPASS) in acute stroke care.

Pain relief in labour: a qualitative study to determine how to support women to make decisions about pain relief in labour.

BACKGROUND: Engagement in decision making is a key priority of modern healthcare. Women are encouraged to make decisions about pain relief in labour in the ante-natal period based upon their expectations of what labour pain will be like. Many women find this planning difficult. The aim of this qualitative study was to explore how women can be better supported in preparing for, and making, decisions during pregnancy and labour regarding pain management. METHODS: Semi-structured interviews were conducted with 13 primiparous and 10 multiparous women at 36 weeks of pregnancy and again within six weeks postnatally. Data collection and analysis occurred concurrently to identify key themes. RESULTS: Three main themes emerged from the data. Firstly, during pregnancy women expressed a degree of uncertainty about the level of pain they would experience in labour and the effect of different methods of pain relief. Secondly, women reflected on how decisions had been made regarding pain management in labour and the degree to which they had felt comfortable making these decisions. Finally, women discussed their perceived levels of control, both desired and experienced, over both their bodies and the decisions they were making. CONCLUSION: This study suggests that the current approach of antenatal preparation in the NHS, of asking women to make decisions antenatally for pain relief in labour, needs reviewing. It would be more beneficial to concentrate efforts on better informing women and on engaging them in discussions around their values, expectations and preferences and how these affect each specific choice rather than expecting them to make to make firm decisions in advance of such an unpredictable event as labour.

The impact of the UK 'Act FAST' stroke awareness campaign: content analysis of patients, witness and primary care clinicians' perceptions.

BACKGROUND: The English mass media campaign 'Act FAST' aimed to raise stroke awareness and the need to call emergency services at the onset of suspected stroke. We examined the perceived impact and views of the campaign in target populations to identify potential ways to optimise mass-media interventions for stroke. METHODS: Analysis of semi-structured interviews conducted as part of two qualitative studies, which examined factors influencing patient/witness response to acute stroke symptoms (n = 19 stroke patients, n = 26 stroke witnesses) and perceptions about raising stroke awareness in primary care (n = 30 clinicians). Both studies included questions about the 'Act FAST' campaign. Interviews were content analysed to determine campaign awareness, perceived impact on decisions and response to stroke, and views of the campaign. RESULTS: Most participants were aware of the Act FAST campaign. Some patients and witnesses reported that the campaign impacted upon their stroke recognition and response, but the majority reported no impact. Clinicians often perceived campaign success in raising stroke awareness, but few thought it would change response behaviours. Some patients and witnesses, and most primary care clinicians expressed positive views towards the campaign. Some more critical participant comments included perceptions of dramatic, irrelevant, and potentially confusing content, such as a prominent 'fire in the brain' analogy. CONCLUSIONS: Act FAST has had some perceived impact on stroke recognition and response in some stroke patients and witnesses, but the majority reported no campaign impact. Primary care clinicians were positive about the campaign, and believed it had impacted on stroke awareness and recognition but doubted impact on response behaviour. Potential avenues for optimising and complementing mass media campaigns such as 'Act FAST' were identified.