Family Practice Vol. 19, No. 4, 378-382
© Oxford University Press 2002
Health care follow-up after stroke: opportunities for secondary prevention
Department of Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, King's College and
a Department of Care of the Elderly, Guy's and St Thomas' Hospital Trust, London, UK.
Judith Redfern, 5th Floor, Capital House, GKT, 42 Weston Street, London SE1 3QD, UK; E-mail: judith.m.redfern{at}kcl.ac.uk
Redfern J, McKevitt C, Rudd AG and Wolfe CDA. Health care follow-up after stroke: opportunities for secondary prevention. Family Practice 2002; 19: 378–382.
Received 20 June 2001; Revised 1 October 2001; Accepted 11 March 2001.
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Abstract |
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Background. Stroke patients have a 15-fold increased risk of a recurrence, but management of risk factors following stroke has been found to be unsatisfactory. Little is known about health service follow-up of patients after stroke or, consequently, the opportunities for providing secondary prevention to patients.
Objective. The aim of the present study was to investigate the relationship between health service follow-up and management of risk factors after stroke.
Methods. The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included risk factor change and follow-up by hospital physicians, GPs and district nurses. Logistic regression was used to determine relationships between these measures.
Results. Seven hundred and seventeen stroke survivors were registered with first stroke between 1995 and 1998. Most patients were followed-up on at least one occasion by at least one service within the first 3 months after stroke: 51% saw a hospital specialist; 72% saw a GP; and 14% saw a community nurse. However, 14% of patients did not see a doctor at all. Disabled patients were less likely to see a doctor, only 17% of severely disabled patients seeing a hospital specialist [odds ratio (OR) 0.17; 95% confidence interval (CI) 0.07–0.41]. Doctor-led follow-up was related to treatment of physiological risk factors (e.g. 73% of hypertensive patients who had seen a GP were treated compared with 59% who had seen only a hospital specialist and 47% who had seen neither). Contact with health services was not associated with behavioural risk factor change.
Conclusions. Opportunities for delivering secondary prevention existed through a range of services, but problems of continuity and effectiveness of care are evident. Further investigation is needed to determine how best to intervene to address these issues. In other words, whether interventions should concentrate on improving access and availability of current services, or whether the focus should be on making current strategies more effective.
Keywords. Prevention, risk factors, stroke.
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Introduction |
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Stroke survivors, who have a 15-fold increased risk of further vascular events compared with the general population,1 are an important group to target if mortality rates are to be reduced.
Secondary prevention requires appropriate management of risk factors, but our previous research indicates that risk factor management in the stroke population is poor (e.g. 30% of patients with hypertension were not treated 3 months after stroke).2,3 In this paper, we now investigate health service opportunities for secondary prevention.
In the UK, as in many other areas of Europe, opportunities for secondary prevention arise through a range of services. These include follow-up by a specialist physician in hospital out-patient clinics, or by a primary care doctor (GP) in a community surgery or in the patient's own home. Other primary care professionals who may provide secondary prevention include the ‘practice nurse’ (whose other duties include providing chronic disease management in partnership with the GP), or a community-based ‘district nurse’ (whose main responsibilities include nursing care, health promotion and preventive activities).4
Research on primary prevention identified failures of follow-up, advice and monitoring as avoidable contributory factors to death from stroke and hypertension.5 Evidence-based guidelines for the delivery of secondary prevention have been produced,6–8 but little is known about current practice. This paper focuses on the following questions: what factors influence patient contact with health professionals? Is contact associated with risk factor management?
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Methods |
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The study used data from the population-based South London Stroke Register, which, since 1995 prospectively collects data on first ever strokes in patients of all age groups. Twelve overlapping referral sources are used to attain complete notification in the study area comprising 22 wards of the Lambeth, Southwark and Lewisham Health Authority (LSLHA), with a population of 234 533. The methodology has been described in detail elsewhere.9
Data were collected on patients' socio-demographic characteristics and risk factors at the time of stroke. Patients were seen by a trained interviewer 3 months after stroke and data collected on: place of residence and functional ability (Barthel Index); physiological risk factors (hypertension, atrial fibrillation, diabetes and coronary heart disease); and behavioural risk factors (smoking, heavy drinking and obesity). Risk factor management 3 months after stroke was defined as treatment with anticoagulant, antiplatelet or antihypertensive medication, smoking cessation and reduction in drinking. Detailed descriptions of patients' risk factors are presented elsewhere.2,3 Data on health service follow-up within 3 months after stroke included: one or more visits to a hospital out-patient clinic or GP surgery, or a home visit from a GP or district nurse.
Data were analysed using chi-square tests and multiple logistic regression.
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Results |
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Between 1 January 1995 and 31 December 1998, 1139 patients were registered with first stroke. Of these, 377 (33.1%) died within the first 3 months after stroke and, of the survivors, 45 (5.9%) did not complete a 3-month follow-up questionnaire. Data from 717/1139 patients are therefore analysed.
Patient characteristics are presented in Table 1
. Most patients (558, 87.5%) had at least one modifiable risk factor at the time of stroke, and 280 (43.9%) had at least two.
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Of those not living in hospital, 317 (55.1%) saw a specialist in an out-patient clinic within the first 3 months after stroke. Care of the elderly specialists were visited most commonly (121, 21.0%), followed by general physicians (56, 9.7%), rehabilitation specialists (44, 7.7%), neurologists (38, 6.6%) and others (55, 9.6%).
Two hundred and sixty-seven patients (44.7%) visited a GP surgery and a further 165 (27.6%) were visited by a GP at home. Patients not initially admitted were more likely to have seen a GP (111, 80.4%) compared with only 328 (70.2%) of those previously hospitalized (P = 0.02). Figure 1 illustrates the overlap between hospital and general practice follow-up. Of those who had no contact with any doctor after leaving hospital, 68 (90.7%) had at least one modifiable risk factor and 26 (34.7%) had at least two. Only patients living at home were eligible for district nurse support. Of these, 85 (14.2%) had seen a district nurse within the first 3 months.
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Associations between follow-up and patient characteristics are presented in Table 2
. Table 3 illustrates relationships between follow-up, patient characteristics and additional risk factors adjusting for all other factors.
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Disabled patients were less likely to have consulted a doctor in any setting (out-patients, GP surgery or at home), but just under two-thirds of severely disabled patients had been visited by a district nurse. Age was also related to GP care, those aged over 65 being less likely to be followed-up and, although elderly patients were more likely to have received support from district nurses, only a quarter of those aged 80 years or more had done so. Those living in nursing homes or residential care rarely attended out-patients although they were equally likely to have seen a GP (all but one receiving a domiciliary visit from the doctor). After adjusting for age and disability, no associations were found between follow-up and gender, ethnicity or social class.
There was no obvious relationship between having additional risk factors at the time of stroke and contact with health professionals. Patients with a diagnosis of diabetes or hypertension were more likely to have been visited by a district nurse, but no other associations were statistically significant.
Ischaemic stroke patients who had seen either a specialist or a GP were more likely to be prescribed medication (Table 4); however, having contact with both did not improve the likelihood of treatment.
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No association was found between follow-up and smoking cessation or reduction of heavy drinking.
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Discussion |
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This is the first study investigating opportunities for secondary prevention in the stroke population. Since most patients had at least one contact with health services in the first 3 months after stroke, there were opportunities for providing secondary prevention. However, 14% did not see any doctor, a quarter did not see a GP and ~10% of those who attended out-patient clinics did not see a stroke-related specialist. Because data were not collected on the reason for patients' contact with professionals, we cannot assume that appropriate secondary prevention was provided to those who were followed-up.
Patients with disabilities were less likely to be followed-up by any doctor. Older patients were less likely to see a GP. These apparent inequalities in service provision require explanation.
Health professionals are encouraged to target those most at risk,6–8 but in this study patients with additional risk factors were no more likely to be followed-up.
Follow-up was not associated with behavioural risk factor change. This is difficult to interpret, but may reflect difficulties in changing behaviours (e.g. quitting smoking). Alternatively, health professionals may choose not to prioritize behavioural risk factors. GPs may be less interested in health promotion or behavioural change,10 finding it difficult to discuss lifestyle issues with patients.11
Since all patients are at risk after stroke, all patients require secondary prevention. Patients with disabilities, the elderly and those living in residential homes may need specific targeting to ensure equitable access to those who can prescribe and monitor their treatment. However, attending services does not in itself constitute risk factor management. Further work is needed to establish what is provided during follow-up and identify facilitators of and barriers to secondary prevention provision.
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Acknowledgments |
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This study was funded by the Northern and Yorkshire Region Research and Development Programme, The Charitable Foundation of Guy's and St Thomas', the Stanley Thomas Johnson Foundation and The Stroke Association.
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References |
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1 Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Long term risk of recurrent stroke after a first ever stroke. Stroke 1994; 25: 333–337.[Abstract]
2 Hillen T, Dundas R, Lawrence E, Stewart JA, Rudd AG, Wolfe CDA. Antithrombotic and antihypertensive management three months after ischaemic stroke: a prospective study in an inner city population. Stroke 2000; 31: 469–475.
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6 Department of Health, National Service Framework for Older People—Modern Standards and Service Models. London: Department of Health, 2001.
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9 Stewart JA, Dundas R, Howard RS, Rudd AG, Wolfe CDA. Ethnic differences in incidence of stroke: a prospective study with stroke register. Br Med J 1999; 318: 967–971.
10 Williams SJ, Calnan M. Perspectives on prevention: the views of general practitioners. Sociol Health Illness 1994; 16: 372–393.
11 Coleman T, Murphy E, Cheater F. Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study. Br J Gen Pract 2000; 50: 207–210.[ISI][Medline]
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