Clinicians' and patients' perspectives on incidentally discovered silent brain infarction
brain infarction (SBI) is a common condition found incidentally on neuroimaging studies
obtained for other indications. SBI increases risk for symptomatic stroke and dementia.
However, despite decades of research on risk factors and outcomes, there is no clear
direction regarding optimal treatment or screening practices for SBI. Currently, in the
absence of evidence-based scr... read moreeening, the only clinically relevant scenario is when SBI
is discovered incidentally in the setting of routine clinical care. To better define
this condition and inform future treatment studies, we sought to explore the
perspectives of clinicians and patients with incidentally discovered SBI. We performed
semi-structured qualitative interviews of patients identified with SBI and clinicians
who encounter patients with SBI in routine clinical practice. We used purposeful
sampling to attain diversity in the clinician and patient characteristics. Interviews
were audio-recorded, transcribed, and analyzed using a constant comparative method to
sort emergent themes into a logical coding schema (codebook) and modify the interview
guide to explore new themes. Fifteen clinicians and twelve patients were interviewed.
The primary themes in the clinician study were uncertainty about SBI and clinical
decision making in response to uncertainty. Clinicians from different specialties
endorsed variable consistency in disclosing the neuroimaging findings to patients and
different levels of aggressiveness in their approach to managing SBI. Although not
universal, clinicians from all specialties endorsed a belief in equivalent prognostic
significance between SBI and symptomatic stroke: "A stroke is a stroke." Most clinician
participants described a willingness to modify clinical practices in response to
comparative effectiveness studies, and many had concerns about the feasibility of
randomized controlled trials. The primary themes in the patient study were patients'
beliefs in the equivalence of SBI and symptomatic stroke and discrepancies between
patients' and clinicians' certainty about the significance of SBI. Most patient
participants did not distinguish between SBI and symptomatic stroke, viewed SBI as
grave, and expressed high levels of distress despite ambiguous messages from clinicians.
Many viewed SBI as a "wakeup call," motivating behavioral changes to improve health. In
response to clinicians' uncertainty, many interpreted ambiguous messages in a
catastrophic way. Incidentally discovered SBI is an unstudied form of an understudied
condition, likely with important health consequences. Among clinicians, there remain
several areas of uncertainty—diagnostic, prognostic, and therapeutic—that
may influence the development of treatment studies for incidentally discovered SBI and
the adoption of clinical practice guidelines. Patients with incidentally discovered SBI
express fear and concern about the condition, equating its significance with symptomatic
stroke. Both clinicians and patients expressed beliefs, attitudes, and preferences that
can inform the development of future studies of this
Thesis (M.S.)--Tufts University, 2017.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: David Kent.
Committee: David Thaler, Paul Han, and Robin Ruthazer.
Keywords: Health sciences, and Medicine.read less