Family Practice Vol. 20, No. 4, 464-468
© Oxford University Press 2003
International Health Care Research |
Transient ischaemic attacks: desired diagnosis and management by Polish primary care physicians
Department of Family Medicine, Jagiellonian University Medical College, ul. Boche
ska 4, 31-061 Kraków, Poland and
a Department of Family Medicine, Utrecht University, The Netherlands.
Correspondence to T Tomasik; E-mail: mmtomasi{at}cyf-kr.edu.pl
Tomasik T, Windak A, Margas G, de Melker RA and Jacobs HM. Transient ischaemic attacks: desired diagnosis and management by Polish primary care physicians.Family Practice 2003; 20: 464–468.
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Abstract |
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Objective. The aim of this study was to assess the competence of Polish primary care physicians in diagnosing and managing patients with transient ischaemic attacks (TIAs) in the carotid territory.
Method. A written questionnaire was distributed to all first-contact physicians (n = 100) in one of the seven health care districts of Warsaw (response rate 89%). The questionnaire included three pairs of TIA cases. In each of the pairs, only the age and type varied. Three cases were characterized by transient monocular blindness and the other three by symptoms of hemispheral ischaemia.
Results. Physicians confronted with TIA cases had difficulties in diagnosing it. In the cases of monocular blindness, only 20–44% of cases were diagnosed correctly, and hemispheral ischaemia was diagnosed correctly in 46–78% of cases. Patients with no history of non-specific symptoms and with the first attack would have a higher percentage of correct diagnoses in comparison with those with recurrent attacks and a history of non-specific symptoms. Patients with hemispheral ischaemia frequently would be referred to neurologists, and about two-thirds of doctors would refer patients with monocular blindness to ophthalmologists, and fewer than half to neurologists. Antiplatelet therapy would be prescribed by <22% of physicians, while peripheral vasodilatators would be prescribed by up to 60% of them.
Conclusion. The results of this study indicate that Polish primary care physicians when confronted with TIA cases would have basic difficulties, especially in diagnosis and management. These results underline the need for changes in the vocational training of primary care physicians, with special attention to frequent family medicine problems.
Keywords. Diagnosis, general practice, management, transient ischaemic attack.
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Introduction |
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The crude annual incidence rate of transient ischaemic attack (TIA) in the European population is between 211 and 422 per 100 000 inhabitants. Patients who suffer a TIA are at an increased risk of a stroke,3 which remains one of the major health care problems in Poland.4
Primary care physicians are often the first to evaluate and treat patients with TIA. Hence, their ability to identify the symptoms and manage the cases can have a significant bearing on the outcome of care.
The aim of this study is to explore whether Polish primary care physicians can correctly recognize and manage patients with TIAs in the carotid territory.
The research questions were: (i) are the written cases (clinical vignettes) of TIA correctly diagnosed by Polish primary care physicians, and does the type of TIA or patient’s age influence the correctness of diagnoses? (ii) What is the prescription, test ordering and referral behaviour of Polish primary care physicians in these TIA cases? (iii) What is the correlation between patient and physician characteristics, respectively, and their management?
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Method |
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A written questionnaire was distributed to all primary care physicians (n = 100) in one of the seven health care districts of Warsaw, the capital of Poland, who provide primary health care to 280 000 inhabitants. Reminders were sent to non-respondents after 2 and 4 weeks.
The first part of the questionnaire recorded the doctor’s personal characteristics: age, sex, year of graduation and type of medical specialization, experience with working in primary care and experience with hospital work.
The second part of the questionnaire included three pairs of cases related to TIAs. Only TIA cases in the carotid territory were used because the vertebra-basilar territory has a relatively low incidence of 
10%.5 The cases contained exactly the same medical information as six cases distributed earlier to Dutch GPs in a similar study.6
Three cases were characterized by transient monocular blindness and the other three by symptoms of hemispheral ischaemia. In all cases, there was information about the number of attacks, age and history of other non-specific symptoms (Table 1
). The three pairs were constructed to allow assessment of the influence of two variables, age and type of TIA, on physician management. In the first pair, only the type of TIA was varied (monocular blindness versus hemispheral ischaemia). In the second (monocular blindness type) and third pair (hemispheral ischaemia type), the patient age (below 65 years versus over 65 years) differed.
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In each case, a description of the patients’ history was followed by one open question regarding diagnostic considerations and five semi-open questions referring to the following aspects of clinical management: (i) additional tests; (ii) medication; and (iii) referrals. Where relevant, the respondent was asked to give more detailed information: (i) type of additional tests; (ii) name of drug; and (iii) type of specialist or hospital ward.
Classification of diagnosis and management
Two doctors (GPs with special interest in vascular diseases) rated the correctness of each diagnosis using a three-point scale as follows: (1) correct; the diagnosis is described in correct terms as TIA; (2) probably correct; the diagnosis is a description of a vascular process but without specification, e.g. cerebral atherosclerosis, vascular pathology, stenosis of carotid artery, stroke; (3) incorrect; no relationship with cerebrovascular disease, e.g. cerebral tumour, retinal detachment. Disagreements were resolved by the third opinion of a neurologist.
The management proposed by the respondents was classified as follows:
- additional investigations (a) blood cell count, (b) plasma glucose, (c) plasma lipids, (d) electrocardiography, (e) Doppler ultrasonography;
- medication: (a) none; (b) prescription of antiplatelet drug; (c) prescription of peripheral vasodilatators;
- referral: (a) no referral, (b) referral to a neurologist or to the hospital department of neurology, (c) referral to an ophthalmologist or to the hospital department of ophthalmology.
Analysis
The Wilcoxon matched-pairs signed rank test was used to explore the relationship between the correctness of the diagnosis and number of additional investigations on the one hand, and the neurological and patient characteristics on the other.7 The sign test was used to explore the relationship between the management strategies and the characteristic of the patient and the history.7 Because the characteristics of the GPs themselves might influence the diagnosis and management,8–11 one-way analysis of variance and Kendall rank correlation were used for analysis. For all these analysis, P 
0.05 was considered statistically significant. Five percent of the data were double coded. All calculations were carried out with SPSSpc.
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Results |
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The response rate was 89%. The mean age of the respondents was 43 years (± SD 12.3); 75% were female. On average, they had 17 years of professional experience as physicians; the average experience of working in primary care was 13 years. Forty-seven percent had previous experience with hospital work. Night hospital duties in addition to their work in primary care were performed by 45%. Thirty-eight of the respondents (43%) had completed vocational training in internal medicine. Six others (7%) had a specialization in a discipline other than internal medicine. Forty-five respondents (more than half) had not completed any postgraduate training.
Diagnosis
The proportion of cases diagnosed correctly as TIA ranged from 20% (monocular blindness, recurrent attacks, history of non-specific symptoms and age over 65 years) to 78% (hemispheral ischaemia, single attack, no history of non-specific symptoms and age over 65 years) (Table 2). Significant differences were found in the pair of cases with hemispheral ischaemia for age. Fewer doctors gave correct and probably correct diagnoses in younger (below 65 years) patients than in older ones. Patients with no history of non-specific symptoms and with the first attack would have a higher percentage of correct diagnosis in comparison with recurrent attacks and history of non-specific symptoms. This difference does not depend on the type of TIA.
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Management
Additional investigations.. More doctors would order blood lipid level determination for patients with monocular blindness than for patients with hemispheral ischaemia (Table 3
). The mean number of additional investigations ordered for patients with monocular blindness was higher than for patients with hemispheral ischaemia. In the cases with symptoms of monocular blindness, more doctors would order electrocardiography and would perform more extensive diagnostics with respect to older patients than to younger ones. There was no difference in the pair of cases with hemispheral ischaemia.
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Pharmacological therapy.. An antiplatelet therapy would be prescribed in fewer than a quarter of cases (Table 4
). In the cases of monocular blindness, significantly more doctors prescribed antiplatet therapy to patients over 65 years than to younger ones. Doctors more often prescribed peripheral vasodilatants to older patients than to younger ones.
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Referral.. In the first pair of cases, more doctors would refer patients with symptoms of hemispheral ischaemia to a neurologist, versus patients with monocular blindness (Table 4
). In contrast, fewer doctors would refer cases of hemispheral ischaemia to an ophthalmologist than cases of monocular blindness. In the pair of cases with hemispheral ischaemia, significantly more physicians referred younger patients to an ophthalmologist than older ones. Doctors’ characteristic.. There were single, inconsistent correlations between physicians’ characteristics (age, gender, type of specialization, experience in primary care or hospital) and correctness of diagnoses or managerial decisions.
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Discussion |
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In Poland, there has never been an investigation into primary care physicians’ performance in TIA cases. Only a few western countries have carried out such studies.6,12,13
The results of our study have demonstrated that Polish primary care physicians had difficulty diagnosing TIA cases. In general, they ordered too few additional tests, seldom referred patients with monocular blindness to a neurologist or hospital and very rarely ordered antiplatelet treatment.
TIA diagnosis can be quite a challenge, even for an experienced neurologist.14 This was illustrated by the wide variety of diagnoses made in patients referred to vascular clinics.15 The percentage of TIA diagnosis errors found in our study exhibited some similarities with those reported in studies by Quik-van Milligen et al.6 and Martin et al.16 These studies found that 80 and 60%, respectively, of cases were diagnosed accurately. Polish primary care physicians were also found to be particularly uncertain about the symptoms of ‘monocular blindness’, as in the study of Ferro et al.12
Additional tests should be performed in all TIA cases in order to identify treatable risk factors and to exclude other diagnoses.17 The number of tests ordered by physicians in our study was too low in comparison with the recommended set.18 Goldstein et al. stated similar findings that 31% of patients with TIA were not hospitalized and had no diagnostic study performed within the first month of introduction to their primary care physician.13
Patients with TIAs who have made a complete recovery and do not require hospital in-patient care ideally should be assessed within a few days in a specialist clinic.19 Although neurologists were easily accessible in the study region, they would be consulted rarely, especially in the cases of monocular blindness. Most such cases would be referred unnecessarily to the ophthalmologist. Our observations are broadly in line with those of Goldstein (33% of patients with TIA consulted)13 and Ferro (50% consulted).12
Antiplatelet drugs are typically the treatment of choice for prevention of strokes in patients who have experienced a TIA of presumed atherothrombotic origin.20 Wiszniewska et al. found that only 12–20% of Polish physicians prescribed these drugs to patients with cerebral circulation disturbances.21 Our results and the Wiszniewska findings both highlight the problem of TIA therapy in Poland which is not based on evidence from randomized trials.22 Furthermore, our findings demonstrate that peripheral vasodilatators are often used, even though their actual benefit remains unconfirmed.23 In other European countries, platelet antiaggregants are used much more frequently (47% of patients) in the management of TIA patients.13
Although our study was restricted to physicians from just one district in Warsaw, there is no reason to believe that the results would be more positive in any other region in Poland. The physicians who took part in the investigation all had the opportunity to increase their knowledge in the field of neurology and unlimited access to most of the necessary investigations. The use of written cases might be criticized because they might not represent actual practice. However, previous studies have indicated the validity of the technique.24 Moreover, this methodology is reliable, simple and inexpensive.
This study provides data reflecting the management of patients with TIA initially evaluated by primary care physicians who had postgraduate training in a hospital internal ward and shows that there is wide scope for improvement. Since the risk of a serious ictus is higher during the first month, all patients with recent TIA should be treated as emergency cases25,26 and require complete investigation, prompt referral and early therapy.22 We believe that the introduction of a new specialty—family medicine—in Poland can improve the treatment of patients with frequent problems. Based on the presented results, postgraduate training should also include neurological diseases, which need urgent evaluation when presented to a family physician.
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References |
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