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hysician Awareness andnowledge of Stroke Practices

ames Burke, MD, and Michael J. Schneck, MD

Physician knowledge and attitudes regarding acute stroke and stroke prevention areincreasing. However, awareness about best practices for diagnosing and managing strokeis still very limited. The approach of many physicians to stroke diagnosis and treatmenteven for such well-studied areas such as TPA for acute stroke, anticoagulation for atrialfibrillation, carotid endarterectomy, and antithrombotic therapy is still very haphazard.There is great potential for improving stroke outcomes simply by improving physicianawareness about currently existing “evidence-based medicine” regarding cerebrovasculardisease.Semin Cerebrovasc Dis Stroke 4:149-154 © 2004 Elsevier Inc. All rights reserved.

KEYWORDS cerebrovascular disease, physician practice, physician awareness, physicianattitudes, atrial fibrillation, antiplatelet therapy, carotid endarterectomy, stroke, diagnosis,TPA, transient ischemic attack

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ver the past two decades, there has been a revolution inthe clinical care of stroke patients. Advances in imaging

ave led to more rapid diagnosis of patients and medical andurgical interventions for acute ischemic stroke and preven-ion of recurrence have led to declines in stroke mortality.owever, the improvement in outcomes that had been antic-

pated following the accumulation of clinical trial data sug-esting that stroke is both treatable and preventable has notaterialized to the rapid extent that was initially anticipated.or example, 10 years after the publication of the NINDS

ntravenous t-PA in acute stroke study, only a small percent-ge of potentially eligible ischemic stroke patients are receiv-ng this therapy. A great deal of emphasis has been placed onnderstanding and changing patients’ awareness abouttroke. The extent to which physician knowledge and aware-ess has been changed is less clear. The limited evidence thatas been gathered might suggest that changing physicianehavior could improve outcomes. However, physicianseed become better versed in stroke diagnosis and treatmentith improved communications between various subspecial-

ies and a wider “across the board” application of evidence-ased guidelines for prevention and treatment of strokecross all disciplines. Several areas mentioned below are

rom the Loyola University Chicago, Stritch School of Medicine, Maywood,Illinois.

ddress reprint requests to: Michael J. Schneck, MD, Department of Neu-rology, Loyola University Medical Center, 2160 South First Avenue,

sMaywood, Illinois 60153. E-mail: mschneck@lumc.edu.

528-9931/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.oi:10.1053/j.scds.2005.04.006

ighlighted regarding physician awareness about diagnosisnd treatment of stroke.

troke Diagnosiso stroke diagnoses get missed? Are opportunities for t-PAsage squandered by unnecessary delays in diagnosis? Beforehe dawn of the t-PA era, less emphasis was placed on rapidnd accurate stroke diagnosis. However, the efficacy of t-PAs predicated on rapid diagnosis as an essential element introke treatment. Since that time, the efficacy of stroke unitsnd of well-coordinated stroke response teams has beenemonstrated.1-3 Ultimately this resulted in a consortium re-ort from the Brain Attack Coalition recommendation for thereation of stroke centers and subsequent accreditation cri-eria of stroke centers by the Joint Commission on Accredi-ation of Health Care Organizations (JCAHO).4 Of note, 79%f emergency physicians, neurologists, and neurosurgeonsgreed with the recommendation to create acute stroke cen-ers, even though they were not entirely clear on the criteriaefining such centers.5

Little data have been gathered on physician performanceince the development of stroke guidelines in the Unitedtates. However, two studies have attempted to identify theactors associated with delay in patient progression outsidehe United States.6,7 Of all prospective variables identified by

ester and coworkers, the most significant finding related toiagnostic criteria and therapy was that patients with less

evere neurologic deficits were less likely to be promptly

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150 J. Burke and M.J. Schneck

reated.6 Improved recognition of stroke symptoms by phy-icians is critical. However, a survey of resident awareness oftroke reported that from a group of primary care (familyedicine, internal medicine, emergency medicine) and neu-

ology residents surveyed, 22% failed to identify dysarthria asstroke symptom and 21% failed to identify obtundation aspossible stroke presentation.8 Neurologists were overallore likely to identify most stroke symptoms as comparedith primary care but only 13% of neurology residents cor-

ectly identified headache as a possible stroke symptom.The ability to accurately identify intracranial hemorrhage

r early infarct signs is an essential element in stroke diagno-is and treatment if only because these findings would repre-ent contraindications to thrombolytic therapy. Schriger andoworkers asked a group of radiologists, neurologists, andmergency medicine physicians to answer the clinical ques-ion of whether a CT scan had evidence of contraindicationso the administration of thrombolytic.9 While all groups wereuccessful at identifying easy hemorrhages (82% success rateor emergency medicine physicians, 100% for neurologists,nd 93% for radiologists), the success rates dropped signifi-antly with more difficult scans (57% for emergency physi-ians, 78% for neurologists, and 80% for radiologists). Sim-larly, performance in identifying acute infarcts variedignificantly among the type of physician and the difficulty ofhe scan. ER physicians identified 82% of easy infarcts against3% of difficult infarcts, while neurologists identified 100nd 44%, respectively, and radiologists identified 93 and0%, respectively. The latter result was confirmed by a studyomparing neuroradiologist performance in identifying earlyigns of stroke with the performance of the physicians typi-ally making the decision to treat with t-PA.10 For the mostart, their results indicate only fair correlation between theonclusions of the treating physicians with the gold-standardeuroradiologist. Clearly, these results raise concern abouthe ability of physicians to identify t-PA exclusion criteria,specially if evidence of acute infarct is included among thoseriteria. Thus part of the reluctance to use t-PA could beelated to physician concern about accuracy of stroke diag-osis.

-PA Usene proffered explanation for the limited utilization of t-PA

s that physicians both doubt its efficacy and fear its sideffects.11 The available data are somewhat conflicted on thealidity of that explanation. Surveys of graduating neurologynd emergency medicine residents indicate significant expe-ience with t-PA and comfort with its utilization. Further, ateast one study has indicated that emergency physicians canafely and effectively utilize t-PA without neurologist evalu-tion. Additionally, the Cleveland, Ohio experience demon-trates that physician education regarding the criteria for in-ravenous thrombolysis is associated with both improvedafety and increased t-PA utilization.12 Still, persistent resis-ance continues in various commentaries purporting to ques-ion the proven efficacy of thrombolysis in stroke.

A survey of graduating neurology residents showed that a

0% had used t-PA on a patient they had cared for and that3% felt comfortable treating patients with t-PA.13 Of theespondents 99% indicated confidence in their ability todentify hemorrhage on CT and 94% were confident theyould identify changes of early infarction. While the 73%ho are comfortable with t-PA utilization certainly exceedshat would have been expected of a similar peer group 5ears prior, neurology residents may overestimate their abil-ty to interpret CT scans as studies have cast doubt on theccuracy of physician identification of early infarcts.9,10 In aimilar survey of emergency medicine residents, only 34.1%ad directly cared for a patient given t-PA, while 73% feltomfortable with their knowledge of thrombolytics.14 Beforetilizing t-PA, 93% of these residents would have demandedn independent reading of the patient’s CT by a radiologist,euroradiologist, or neurologist. Arguing against the thesishat emergency physicians are reluctant to use t-PA due tooubts of its efficacy, 88.2% of the sampled populationould want to be given t-PA if they presented with an acute

troke and only 3.9% would not prescribe t-PA under anyircumstances.

A prospective study comparing the efficacy and safety ofmergency physicians who prescribed t-PA with only a tele-hone consultation with a neurologist and radiologist with-PA prescription by a neurologist found no significant dif-erence in outcomes.15 Given the combination of stated emer-ency medicine resident comfort with t-PA and evidence ofafe t-PA utilization by emergency physicians, one mightonclude that improving physician education about t-PAould not further increase utilization. However, a prospec-

ive comprehensive community-based education programoncluded otherwise.16

Akins and coworkers describe a study in which an educa-ion and awareness campaign was directed at both the com-unity and the health care providers.15 To measure efficacy

f the campaign, the primary outcome of percentage of pa-ients treated with t-PA was compared with a separate, butnitially similar community. In the intervention community-PA utilization increased from 1.38 to 5.75%, while thereas no significant change in the control community. In both

ommunities the mean time to presentation decreased andhere was no significant change between the communities inhe magnitude of the decrease. Consequently, the authorsonclude that the positive effects of the intervention wereaused primarily by changes in physician behavior. The sameuthors have subsequently demonstrated that there haveeen lasting effects of the education campaign after it wasiscontinued.17 This suggests that physician behavior regard-

ng treatment of acute stroke can be modified.

trial Fibrillationeveral trials in the late 1980s and early 1990s described thefficacy of warfarin as compared with aspirin for stroke pre-ention in atrial fibrillation. Pooling the data from those trialsielded a net 68% relative risk reduction and an absolute riskeduction of 3.1% from the pooled baseline risk of 4.5%

nnually.18 The analysis also demonstrated that the annual

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Physician awareness and knowledge of stroke practices 151

ate of bleeding in the warfarin treatment groups was 1.3%ompared with 1.0% in the control groups. As these resultsere published and as physician practice patterns changed,

he overall utilization of oral anticoagulants in atrial fibrilla-ion increased from 14.6% in 1985-1988 to 47.6% in 1995-997.19 While that trend clearly documents increasing phy-ician awareness of the utility of warfarin in treatment ofatients with atrial fibrillation, several more recent studiesave reported that warfarin continues to be significantly un-erprescribed to patients with atrial fibrillation in manyountries. In Italy, one study revealed that 20% of patientsith documented atrial fibrillation at high or moderate risk

or stroke were not receiving oral anticoagulants, despite thending that only 11% of patients had a documented contra-

ndication.20 A chart audit of two United Kingdom hospitalsevealed that only 47% of patients were correctly managedccording to their management algorithm of oral anticoagu-ation for patients with atrial fibrillation at high risk fortroke.21 After presenting those results to staff and runningeveral educational programs, a follow-up audit 6 monthsater found that algorithm compliance increased to 75%ithout significant changes in the underlying patient popu-

ation. However, a retrospective analysis of a Swedish strokeegistry showed that only 11% of patients presenting with atroke and atrial fibrillation were receiving oral anticoagu-ants.22 Of patients presenting with a stroke and atrial fibril-ation after a prior stroke, only 33.5% were treated with an-icoagulants. In the SAFE-2 trial, the authors found that only2.2% of patients presenting with stroke and atrial fibrilla-ions were on oral anticoagulants, 48.9% were on antiplateletgents, and 28.9% were not receiving any treatment.23 Theuthors in both cases conclude that oral anticoagulants arenderutilized for both primary and secondary stroke preven-ion. Bungard and coworkers agreed that oral anticoagulantsre underused, noting that only 15 to 79% with atrial fibril-ation are treated. Further, they asserted that physician per-eption of risk/benefit ratio is the primary determinant ofhether patients receive oral anticoagulants.24 Overall, in thenited States, there continues to be underutilization of war-

arin for stroke prevention in patients with atrial fibrillationnd, despite widespread publicity, there has not been a sig-ificant increase in that utilization over the past several years.wo years ago, a study was published as a follow-up to aeport looking at 22 different measures of quality of carerovided to Medicare beneficiaries in 1998 to 1999.25 Theuthors of the follow-up study noted some improvement inare from 1998 to 1999 as compared with 2000 to 2001.26

owever, the use of warfarin continued to be woefully inad-quate. In 1998 to 1999 warfarin was prescribed to only 55%f patients with atrial fibrillation for whom there was noocumented contraindication. Two years later, there wasnly a 3% increase in warfarin utilization.Agreement about warfarin being underutilized is not uni-

ersal, however. Weisbord and coworkers conducted a med-cal record review at a tertiary care Veterans Affairs Medicalenter and included a detailed analysis as to why patientsith documented atrial fibrillation were not prescribed war-

arin.27 In this study, three serial analysts carefully looked at v

atient records with a diagnosis of atrial fibrillation. Of pa-ients with an ICD-9 code suggesting atrial fibrillation whoere not receiving warfarin, 44% actually had no docu-ented atrial arrhythmias, 28.6% had a documented contra-

ndication to warfarin, and only 11.4% appeared to have nobvious justification for not being treated. Minimally, thisesult brings to light the dependence of methodology on thessessment of physician compliance with guidelines.

Physician attitudes as explored through surveys and audit-riggered questioning suggest less than optimal understand-ng the risk/benefit ratio associated with oral anticoagulants.n the SAFE-2 trial of patients with atrial fibrillation, 35.2%f general practitioners and 37.5% of cardiologists statedhere was no indication for treatment, while 22.6% of generalractitioners and 27.7% of cardiologists cited “fear of hem-rrhage” without evidence of other contraindications as aeason for not prescribing warfarin.22 Another physician sur-ey suggested that physicians often overestimate the risks ofarfarin and underestimate its benefit.28 Physicians esti-ated the annual risk reduction of stroke at 53% comparedith the consensus value of 68%. Further, physicians signif-

cantly overestimated the risk of hemorrhage at 10% com-ared with the consensus value of 1.3%. An interview ofhysicians and patients at risk of developing atrial fibrillationound that the groups have differing thresholds of the benefit/isk ratio of stroke prevention relative to hemorrhage.29 Pa-ients would hypothetically require only a 1.8% absolute riskeduction before instituting treatment, whereas physiciansesired a 2.5% absolute risk reduction before they wouldrescribe the medication.

arotid Endarterectomyfter falling during the late 1980s, the number of procedureserformed in the United States and Canada has increased tohe approximate level from which they had fallen in the mid-980s.30 As clinical trials have shown a benefit for surgicalver medical management for both symptomatic and asymp-omatic carotid stenosis, the result is not surprising.31 How-ver, while there is an emerging international consensus onhe appropriateness of endarterectomy for symptomatic ste-osis, physicians in the USA are more likely to utilize therocedure than their counterparts in Western Europe andanada for asymptomatic patients though even USA physi-ians are more reluctant to utilize carotid endarterectomy insymptomatic than in symptomatic patients.

Compared with their counterparts in the UK, primary carehysicians in the United States are more likely to obtainurther diagnostic information in patients with asymptomaticruits.32 Seventy percent of USA physicians would order ca-otid ultrasounds in these patients, whereas only 14% ofhysicians would do so in the UK according to their surveyesponses. American physicians also more aggressively pur-ued carotid disease after recent transient ischemic attacksTIAs) or minor strokes than did their British counterparts. Inhe USA doctors ordered more carotid ultrasound studies80% versus 11%), referred to neurologists more often (55%

ersus 44%), and referred to surgeons more often (39% ver-

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152 J. Burke and M.J. Schneck

us 19%) as compared with the UK. Another survey showedSA residents are enthusiastic about CEA for symptomaticatients though less so for asymptomatic patients.8 Further-ore, while the surveyed residents had a good understand-

ng of the means of diagnosing and treating carotid stenosis,heir responses suggest they are not fully aware of publishedreatment guidelines. Forty-five percent of the surveyed res-dents would actually recommend CEA for symptomatic pa-ients with less than 60% stenosis. The residents were, how-ver, more reserved in their recommendations for interventionn asymptomatic patients. Only 45% would recommend sur-ery for patients with greater than 85% stenosis and only 7%ould recommend surgery for patients with 60 to 70% ste-osis.Surveys of neurologist attitudes toward CEA reveal differ-

ng practices in different geographic regions. Forty-eight per-ent of surveyed North American neurologists would recom-end CEA for asymptomatic patients compared with only

8% of Western European neurologists.33 Similar differencesave been reported between the United States and Canada.lorida neurologists would refer asymptomatic patients withignificant stenosis for surgery up to 65% of the time, whilenly 11% of Canadian neurologists would refer similar pa-ients to surgery.34 The differing behaviors might not simplye a consequence of either complication rates or data inter-retation as Florida neurologists noted medicolegal concerns

mpacted their decision to refer to surgery in 27% of cases,hile medicolegal concerns only effected the decision mak-

ng process for 3% of Canadian neurologists.

isk Factor Managementuidelines for management of diabetes, hypertension, andyperlipidemia have existed for some time. However, numer-us studies have demonstrated that risk factor managementor primary or secondary stroke prevention continues to benadequate. One representative study was a comprehensiveisk factor analysis among African American patients demon-trating that 61% of hypertensives receiving antihypertensiveedication had pressures over 140/90.35 In the study popu-

ation, 49% of the patients who stated they did not haveypertension had pressures over 140/90. Similar results wereeen for diabetes and cholesterol management. Thirty-twoercent of the studied diabetic patients had a random bloodugar greater than 200 and 25.8% of patients with knownyperlipidemia met the older NCEP-II criteria for “high” cho-

esterol with a total cholesterol �240 and an HDL �35; 23%ithout known hyperlipidemia met the criteria for high cho-

esterol.Less than ideal physician awareness of guidelines may playpart in the failure to adequately manage the risk factor

urden in stroke patients. A large survey of German physi-ians showed that only 37.1% of cardiologists, 25.6% of in-ernists, and 18.6% of general practitioners had adequatenowledge of guidelines.36 Another large Italian surveyound that only 16% of the surveyed general practitionersnd 14% of those surveyed working in diabetes clinics cor-

ectly identified the guideline-based target BP of 130/85.37 Of a

he patients treated by these physicians, only 6% had a BP lesshan the target, while 52% had a BP �160/90 and suggestivevidence for the concept that physician lack of knowledge ofuidelines correlates with poor patient guideline compliance.Chinese survey also found overall awareness of diagnostic

nd treatment guidelines for hypertension to be lacking.38

ost strikingly, only 34.9% of cardiologists, 33.9% of neu-ologists, and 25.4% of internal medicine physicians cor-ectly answered the survey questions about the diagnosticriteria for hypertension.

Another reason for imperfect guideline application may behat patients have a higher risk threshold than do physicians.n a survey of Canadian family physicians and patients, usinglinical vignettes to assess attitudes, physicians demonstratedstronger preference for antihypertensive therapy at all levelsf risk than did their patients.39 Given a 10-year 2% risk ofardiovascular event, 49% of patients and 64% of physiciansould prefer treatment. Similar results were found with 5

nd 10% risk profiles (68% versus 92% and 86% versus00%).Effective communication between physician and patient

oncerning cerebrovascular risk may be lacking. First, phy-icians may not recognize prior stroke as a variable of com-arable importance to coronary heart disease when makingecisions to treat for hyperlipidemia.40 Second, to the extenthat physicians recognize various cardiovascular risk factors,hat risk may not be adequately conveyed to patients. A sur-ey of both physicians and their patients showed that while8% of physicians state they discuss cerebrovascular riskith their diabetic patients, far greater numbers of patientsoted blindness (65%) or amputation (36%) as a risk of theiriabetes as compared with stroke (5%).41

revention withntiplatelet Agents

here has been sufficient evidence for the role of antiplateletgents in secondary prevention of stroke such that the Amer-can Heart Association has published guidelines recommend-ng the use of aspirin or other antiplatelet agents in all pa-ients with a prior stroke without the presence of aontraindication.42 However, this is another instance whereuidelines are not ideally applied. A large study analyzed datarom a database of patients admitted to home care programsfter a stroke. The authors found that 70% of patients wereot on an antiplatelet or anticoagulant at the time of admis-ion to the home care program.43 Other studies have alsooncluded that aspirin is underprescribed.44 Yet, there isome cause for optimism. The 2003 report on quality of carendicators in Medicare patients reported that 84% of patientst discharge following a stroke were treated with antithrom-otic therapies.26 Additionally, a prospective study followingatients admitted after stroke found that 87.6% of patientsere still on an antithrombotic agent 1 year after discharge.45

To better understand why aspirin is underprescribed in aopulation where a clear benefit has been described, Short

nd coworkers performed a set of extensive interviews with

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Physician awareness and knowledge of stroke practices 153

eneral practitioners to elucidate practical difficulties in ap-lying accepted guidelines.46 The majority of participants inhis qualitative study recognized the beneficial effects of as-irin and did not believe their prescribing practices wereuboptimal. Yet, after closer interrogation, they unearthed aumber of potential reasons aspirin might be underutilized.mong the many potential explanations were difficulty inetermining whether a patient’s stroke was hemorrhagic or

schemic, patient reluctance to take aspirin, infrequent visitsor patients with prior stroke, a general disregard for aspirinhen compared with newer medications, and a general con-

ideration that applying guidelines in real patient popula-ions is often more complicated that it seems. Hagemeisternd coworkers echoed the last point in an analysis of physi-ian compliance with hypertension guidelines.36

ransient Ischemic Attacksery little literature has been specifically aimed at physicianwareness of TIAs. One study illustrated both differencesetween stroke and TIA management by primary care pro-iders and some general trends in cerebrovascular diseaseanagement.47 This retrospective medical record audit of

rimary care practitioners (PCPs) demonstrated that PCPsarely admit patients with new onset stroke (6% of patients).atients presenting to PCPs received some form of imaging in0% of cases, carotid ultrasounds in 20% of cases, and spe-ialists were consulted 45% of the time. A survey of primaryare physicians demonstrated good awareness of TIA riskactors and treatment options, but a limited understanding ofhe definition of a TIA.48 At least 98% of PCPs separatelydentified atrial fibrillation, hypertension, diabetes, smoking,yperlipidemia, and heart disease as TIA risk factors. Eighty-ight percent would recommend endarterectomy in patientsith TIA and severe carotid stenosis and 93% would recom-end oral anticoagulation most of the time in atrial fibrilla-

ion. However, PCPs did not demonstrate a comparably goodnderstanding of the diagnostic criteria for TIAs. Only 22%

dentified all five typical TIA symptoms and knew that a TIAhould last less than 24 hours. Fifty-seven percent believedymptom duration longer than 24 hours was consistent withTIA diagnosis.

oom for Improvementurveys that assess physician knowledge consistently dem-nstrate less than ideal knowledge of the subject studied,articularly when analyzing physician knowledge of guide-

ines. In a similar vein, numerous studies that analyze largeatient populations have found that a disproportionate num-er of patients are not receiving care consistent with theecommendations of published guidelines. From these ob-ervations, one might conclude that physician complianceith guidelines needs significant improvement. However,ther studies have not confirmed significant physician devi-tion from guidelines.24,42 Further, studies of patient prefer-nces suggest that at least some of the variance between ac-

ual clinical practice and guideline may be due to differing

isk perception between patients and physicians.24,35 Inhort, there are no easy general conclusions about physician’snowledge and awareness about cerebrovascular disease, buthe preponderance of data indicates that physicians could doetter. The experience of a large private practice cardiologyroup in suburban Chicago shows how built-in quality con-rol procedures could increase physician compliance witherceived recommendations.49 Improved compliance by in-roducing checks at the pharmacist level and use of pharma-ist- and nurse-managed programs such as utilization of war-arin clinics also increased the number of patients receivingnticoagulation for atrial fibrillation.50,51 Computerized deci-ion support systems have also allowed doctors to make moreonfident decisions.52 The common thread among these suc-essful or potentially successful interventions seems to beransferring the responsibility to attend to every detail ofatient care from the physician to a more robust systemhere the physician has support from other personnel or

ystems. It seems plausible to suggest that in the same wayhat careful multidisciplinary communication combinedith thoughtful organization has been able to improve acute

troke outcomes that stroke prevention might benefit fromimilar organization.

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