Barriers and facilitators to intracerebral haemorrhage platform trial recruitment: a survey of stroke clinicians

A UK-wide survey of stroke clinicians reveals strong support for a future intracerebral haemorrhage platform trial, identifying the perceived importance of the research question as a key facilitator while highlighting clinician treatment preferences, staffing, and study design complexities as primary barriers to recruitment.

The Gist

Imagine the medical world is trying to fix a very tricky problem: bleeds in the brain (called intracerebral haemorrhage, or ICH). Right now, doctors have great ways to manage the situation, but they don't have a specific "magic pill" or treatment that stops the bleeding or heals the brain effectively. They need to test new ideas, but doing so is like trying to find a needle in a haystack while the haystack is on fire.

Here is a simple breakdown of what this paper is about, using some everyday analogies.

The Big Idea: The "All-You-Can-Eat" Trial vs. The "Single Dish" Trial

Traditionally, when doctors want to test a new medicine, they run a single trial. It's like opening a restaurant that only serves one specific dish (e.g., just spaghetti). They have to build the whole kitchen, hire the staff, and find customers just to test that one spaghetti recipe. If they want to test a salad next, they have to close the restaurant, rebuild the kitchen, and start all over again. This is slow, expensive, and frustrating.

Platform Trials are the solution the authors are excited about. Think of a platform trial as a giant, high-tech food truck that has a rotating menu.

• It has one big kitchen (the infrastructure).
• It can test multiple dishes (different treatments) at the same time.
• If a dish is bad, they take it off the menu. If a dish is amazing, they keep it.
• They can add new dishes without rebuilding the whole truck.

The goal of this paper was to ask the chefs (the doctors and nurses) if they would be willing to work in this new "food truck" to help find better treatments for brain bleeds.

The Survey: Asking the Chefs

The researchers sent a questionnaire to 73 stroke specialists across the UK. They wanted to know:

1. Do you think this "food truck" idea is a good plan?
2. What makes it easy for you to get customers (patients) to try the food?
3. What makes it hard?

The Results: The Chefs Love the Idea (Mostly)

The Verdict:
A huge majority (91%) said, "Yes! This is a great idea." They are eager to test multiple treatments at once to speed up finding a cure.

The Good Stuff (Facilitators):
The chefs said the "food truck" will work best if:

• The Menu is Clear: The instructions for patients need to be short, simple, and easy to understand (like a clear picture menu, not a 50-page legal document).
• The Timing is Right: In a brain bleed emergency, you can't wait for a patient to sign a long paper form while they are in pain. Doctors said they need to be able to get a quick "verbal yes" first, and fill out the paperwork later. It's like getting a nod of approval before the ambulance leaves, rather than waiting until they get to the hospital.
• The Team is Ready: If the hospital staff already loves doing research, it's much easier to get people to join the trial.

The Bad Stuff (Barriers):

• The "I Prefer My Own Recipe" Problem: The biggest hurdle was doctors' personal preferences. Some doctors are so convinced that their specific way of treating a patient is the best that they don't want to let a computer decide which treatment the patient gets (randomization). It's like a chef refusing to let a customer try a new dish because they insist the old one is better.
• Being Overworked: Many doctors said they are already running on empty. They don't have enough time or extra staff to manage a complex new trial. They need more "sous-chefs" (research staff) to help them.

The Two Big Hurdles: "The Blueprint" and "The Crew"

When the doctors wrote extra notes, their complaints fell into two buckets:

1. The Blueprint (Study Design):

   • The Problem: The rules for joining the trial are too complicated.
   • The Fix: Make the rules simple. If a patient is eligible, let them in quickly. Don't make the doctors fill out endless forms. Use videos and simple language to explain the trial to families.

2. The Crew (Infrastructure):

   • The Problem: There aren't enough hands on deck.
   • The Fix: Hospitals need to hire dedicated research staff so that regular doctors don't have to do it all on their own. They also need better training so everyone understands how this "food truck" works.

The Bottom Line

The doctors are ready and willing to help build this new, faster way of testing treatments for brain bleeds. They believe it could save lives.

However, for this to work, the researchers need to:

• Keep the paperwork simple and fast.
• Make sure the doctors feel confident and trained.
• Give the doctors extra help (staff) so they aren't overwhelmed.

If they do these things, this "food truck" could serve up life-saving treatments much faster than ever before. If they don't, the doctors might get too busy or confused, and the truck might never leave the garage.

Technical Summary

1. Problem Statement

Intracerebral haemorrhage (ICH) remains a condition lacking specific, proven medical treatments despite advances in integrated care bundles. Traditional Randomised Controlled Trials (RCTs) for ICH are often small, time-consuming, and inefficient. Platform trials—a design allowing the simultaneous testing of multiple interventions using a shared infrastructure—are proposed as a more efficient method to accelerate the identification of effective treatments. However, the success of such trials relies heavily on successful patient recruitment. There is a lack of empirical data regarding the views of UK stroke clinicians on the feasibility, barriers, and facilitators specific to recruiting patients into a future ICH platform trial.

2. Methodology

• Study Design: A cross-sectional, UK-wide online survey conducted between April and July 2025.
• Participants: 73 clinicians actively involved in stroke research, recruited via convenience sampling through professional networks (e.g., NIHR Stroke Research delivery network, British and Irish Association of Stroke Physicians, National Stroke Nurse Forum). The cohort included stroke physicians (50%), nurses (34%), allied health professionals (8%), and others.
• Data Collection:
  • Quantitative: Participants rated 11 modifiable factors (related to consent processes and the research environment) on a 5-point Likert scale ranging from "strong barrier" to "strong facilitator."
  • Qualitative: Optional free-text responses were collected regarding additional barriers and facilitators.
• Analysis:
  • Quantitative data were analyzed using descriptive statistics in Microsoft Excel.
  • Qualitative data underwent inductive content analysis. Two researchers independently coded the free-text responses to identify recurring themes, resulting in a framework of two overarching categories: Study Design and Research Infrastructure.
• Ethics: Approved by the University of Edinburgh Research Ethics Committee; data were collected anonymously.

3. Key Contributions

• First-of-its-kind Survey: This is the first study to specifically investigate stroke clinicians' perspectives on recruitment for ICH platform trials.
• Dual-Mode Analysis: It uniquely combines quantitative rating of specific factors with qualitative thematic analysis to provide a holistic view of recruitment challenges.
• Actionable Framework: The study moves beyond general barriers to propose specific, modifiable solutions categorized into study design (e.g., consent, materials) and infrastructure (e.g., staffing, governance).
• Stakeholder Engagement: It highlights the critical role of early stakeholder involvement in shaping trial design to ensure feasibility and clinician buy-in.

4. Key Results

Demographics & General Sentiment:

• 91% of respondents (66/73) agreed that a platform trial is a good option for testing ICH interventions.
• The majority of respondents had significant clinical experience (>20 years for 49%) but limited time dedicated to research (<10% of role for 61%).

Quantitative Findings (Barriers & Facilitators):

• Top Facilitator: The perceived importance of the research question (rated as a facilitator by 94%).
• Top Barrier: Clinician preference for specific treatments (rated as a barrier by 48%).
• Consent & Environment:
  • 84% viewed the ability to seek verbal consent before written consent in hyperacute settings as a facilitator.
  • 92% viewed prior research experience as a facilitator.
  • 91% viewed a research-positive culture within the clinical team as a facilitator.
  • 79% valued the option to share participant information electronically.

Qualitative Findings (Thematic Analysis):
Two primary themes emerged from free-text responses:

1. Study Design:

   • Consent Processes (n=9): Strong demand for streamlined, inclusive processes, including access to independent legal representatives and deferred (retrospective) consent for emergency settings.
   • Study Materials (n=8): Need for clear, accessible, and visual materials (videos, simplified language) available in multiple languages.
   • Procedures & Eligibility (n=8 & n=6): Emphasis on minimizing burden through pragmatic study procedures and clear eligibility assessment pathways.
   • Randomization (n=3): Concerns regarding the complexity of randomization in a multi-arm setting.

2. Research Infrastructure:

   • Staffing (n=17): The most cited issue. Respondents emphasized the need for adequate full-time research staff to support multi-site delivery and out-of-hours recruitment, rather than relying solely on clinical staff.
   • Local Culture & Capacity (n=9): The necessity of embedding research into routine workflows and fostering a research-positive culture.
   • Governance & Delivery (n=6): Need for streamlined national governance, reduced administrative burden, and digital integration (e.g., NHS App).
   • Training (n=6): Specific education on platform trial designs and adaptive methodologies is required to build clinician confidence.

5. Significance and Implications

• Clinical Practice: The findings suggest that for an ICH platform trial to succeed, it must prioritize operational simplicity and feasibility. Complex protocols and administrative burdens are likely to deter clinician engagement.
• Regulatory & Ethical Reform: The strong support for deferred consent and verbal consent in hyperacute settings aligns with emerging UK regulatory reforms aimed at simplifying consent for low-risk trials. This study provides empirical backing for these changes in the context of stroke.
• Trial Design: Future ICH platform trials must address clinician preference bias by clearly defining the "usual care" context and standardizing recruitment messages to ensure uncertainty is framed consistently across sites.
• Resource Allocation: The data underscores that recruitment success is not solely a clinical issue but an infrastructural one. Adequate funding for dedicated research staffing and training is a prerequisite for the viability of such trials.
• Future Directions: The authors recommend future work to test proportionate consent approaches (e.g., staged consent pathways) and to conduct qualitative research with patients and families to ensure these recruitment strategies are ethically robust and acceptable to the public.

Limitations: The study is subject to potential responder bias (clinicians with favorable views may be more likely to respond), lacks representation from Wales and Northern Ireland, and could not calculate a precise response rate due to the convenience sampling method.