Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective

Abstract

Background: Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia.

Methods: A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.

Results: Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.

Conclusions: In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.

Keywords: Acute stroke care; Determinants; Developing countries; Factors; Intravenous thrombolysis; Translational research.

Fig. 1

Relationship between contributing factors and its respective overarching domain to the provision of intravenous thrombolysis. Grey boxes refer to factors within the specified domain

Fig. 2

Reasons for non-thrombolysis among ischemic stroke patients in respective participating hospital. TIA: Transient ischemic attack; NIHSS: National Institutes of Health Stroke Scale; potential missed opportunity includes those with delayed referral to CT imaging and delayed assessment by stroke team. Unknown reasons in Hospital X refers to potentially eligible patients by timing but may have other reasons to not receive thrombolysis