This implies that changing physician practice with regard to stroke thrombolysis may not require changing minds, per se. Instead, increasing physician familiarity,

confidence (self-efficacy), and motivation to deliver the treatment are likely to be of higher yield. Further investigation of the limited guideline disagreement Wnt inhibitor perceived by EPs will be needed. Further conclusions on this topic may be facilitated through quantitative survey data. In addition, a small number of hospitals seemed to have clusters of higher perceived guideline disagreement. This suggests that clustering within physician groups is an important consideration for evaluating and improving barriers to care. Our separate interviews with Inhibitors,research,lifescience,medical nurses and EPs provided unique findings. The repeated re-examination phenomenon was described by emergency

department nurses. This specific example typifies the perceived barrier that was cited as most important by many nurses: lack of motivation. The picture that is painted is that of the clinician who Inhibitors,research,lifescience,medical is uncomfortable and unsure when faced Inhibitors,research,lifescience,medical with the potential of having to administer a thrombolytic agent. It is doubtful if this barrier would have been articulated as clearly without interviews restricted to individual provider types. This work has several important limitations. We did not generally seek “saturation” Inhibitors,research,lifescience,medical by performing repeat focus groups with the intent of further delving more deeply into specific themes. We used an existing taxonomy to classify responses, which might have missed barriers that did not fit well into any of the categories. The integration of these results with quantitative methods and overall response to the targeted educational interventions (as evidenced by change in tPA treatment rates), is not possible at this point in the overall trial. We focused only on 12

hospitals within Michigan, and while these hospitals came from diverse geographic and socioeconomic areas, Inhibitors,research,lifescience,medical these findings may not be widely generalizable. There is a potential that participants in the focus groups and interviews were generally more positive towards stroke thrombolysis, although it is also plausible that participants with strong negative opinions would also be extremely motivated to participate. Overall it appears that a range of opinions were represented by our participants. This contributes to the richness of CYTH4 the findings of the current investigation. Conclusions In summary, healthcare providers responsible for acute stroke treatment perceive environmental and patient factors as the most important barriers to adherence with the AHA acute stroke guidelines. With respect to internal barriers, nurses perceived lack of guideline familiarity as the biggest barrier whereas physicians (both EPs and neurologists) perceived physician motivation as the primary barrier.