Practice variation in long-term secondary stroke prevention in the Netherlands

Transcription

1 C H A P T E R 8 Practice variation in long-term secondary stroke prevention in the Netherlands Sander M. van Schaik Blanche S. de Vries Henry C. Weinstein Marieke C. Visser Renske M. van den Berg-Vos Journal of Stroke and Cerebrovascular Diseases 2015;24: _final opmaakbestand.indd :21

2 A B S T R A C T Background Stroke guidelines emphasize the importance of adequate vascular risk factor assessment and management in transient ischemic attack (TIA) and ischemic stroke patients, but it is not clear how these guidelines are applied in routine clinical practice. The limited data that are available indicate that TIA and ischemic stroke patients often do not receive the recommended interventions. The aim of this study was to investigate practice variations in long-term secondary stroke prevention in the Netherlands. Methods Between June and December 2013, an invitation for a web-based survey was sent to 90 Dutch neurologists with a special interest in stroke neurology. This web-based survey contained questions regarding the organization of outpatient care for TIA and ischemic stroke patients after initial hospital assessment, pharmacologic treatment, and nonpharmacologic strategies for long-term secondary prevention. Results In total, 84 (93%) neurologists completed the survey. Although nearly all respondents reported that they follow-up TIA and ischemic stroke patients after initial hospital assessment, the number of follow-up visits and the follow-up duration were variable. A similar variation was found in treatment targets levels for both blood pressure and low-density lipoprotein cholesterol. Regarding nonpharmacologic strategies for long-term secondary stroke prevention, most respondents inform their TIA and ischemic stroke patients about the importance of smoking cessation. There is considerably less attention for the other lifestyle risk factors. Conclusions We found considerable practice variation in long-term secondary stroke prevention. These variations may have an impact on the risk for stroke recurrence and cardiovascular disease in general. 126 _final opmaakbestand.indd :21

3 Introduction Stroke is a major cause of death and disability world-wide. Evidence from randomized trials and meta-analyses for the effectiveness of long-term secondary prevention strategies after transient ischemic attack (TIA) and ischemic stroke is compelling. A combination of antithrombotic therapy, blood pressure control, statins, dietary modification, and exercise lowers the risk of recurrent stroke and other future cardiovascular events. 1-5 The combination of these strategies could result in a cumulative relative risk reduction of 80%. 6 Therefore, national and international guidelines emphasize the importance of adequate risk factor assessment and management in TIA and ischemic stroke patients, but it is not clear how these guidelines are applied in routine clinical practice Few studies have focused on the quality of care regarding long-term secondary stroke prevention. The limited data that are available indicate that despite advances in treatment, TIA and ischemic stroke patients often do not receive the recommended interventions We hypothesized that considerable variations in long-term secondary stroke prevention may exist among neurologists in the Netherlands. We used an online survey to seek the opinion of Dutch neurologists about long-term secondary stroke prevention. The results of this survey can be used to improve future quality of care for these patients. M e t h o d s We analyzed national and international TIA and ischemic stroke guidelines to identify topics and situations where practice variation, regarding long-term secondary prevention for TIA and ischemic stroke patients, could be expected. An online survey creator ( 127 _final opmaakbestand.indd :21

4 C H A P T E R 8 : P R A C T I C E V A R I A T I O N I N L O N G - T E R M S E C O N D A R Y S T R O K E P R E V E N T I O N I N T H E N E T H E R L A N D S was used to develop a web-based survey, which included multiple choice questions, multi-answer multiple choice questions, and free-text fields for additional comments. This survey was divided into 3 parts. The first part contained questions on how outpatient care for TIA and ischemic stroke patients is organized after initial hospital assessment (Table 1). The second part of the survey consisted of questions about pharmacologic treatment regarding long-term secondary stroke prevention (Table 2). The third part contained questions regarding nonpharmacologic strategies for long-term secondary stroke prevention (Table 3). Between June and December 2013, an invitation for an anonymous web-based survey was sent to 90 Dutch neurologists with a special interest in stroke neurology, working in 90 different hospitals. Most of them participated in an earlier online survey on variation in clinical practice of intravenous thrombolysis in stroke in the Netherlands. 15 To increase the response rate, a monthly reinvitation was sent. Results Ninety neurologists were invited to participate, of whom 84 (93%) completed the survey. Most of the respondents (92%) worked in nonacademic hospitals. The Organization of Outpatient Care for TIA and Ischemic Stroke Patients Almost all respondents (98%) reported that they follow-up TIA and ischemic stroke patients after initial hospital assessment. The average number of follow-up visits were variable, ranging from 1 visit in 34 (40%) respondents to 4 visits or more in 2 (2.4%) respondents. The follow-up duration ranged from 0-3 months (62%) to 12 months or more (4.8%). Respondents reported that during follow-up patients are managed by neurologists (76%), neurology residents (15%), physician 128 _final opmaakbestand.indd :21

5 TABLE 1 Questions regarding the organisation of long-term secondary prevention after TIA and ischemic stroke Questions n (%) Do you follow-up TIA and ischemic stroke patients after initial hospital assessment? Yes 82 (98) No 2 (2.4) What is the average number of follow-up visits? 1 visit 34 (40) 2 visits 37 (44) 3 visits 9 (11) 4 visits ore more 2 (2.4) Did not specify 2 (2.4) What is the average follow-up duration? 0-3 months 52 (62) 4-6 months 18 (21) 7-12 months 8 (9.5) >12 months 4 (4.8) Did not specify 2 (2.4) Who does manage your patients after TIA and ischemic stroke with regard to long-term secondary prevention? (more than one answer allowed) Neurologist 64 (76) Neurology resident* 13 (15) Physician assistant 26 (31) Stroke nurse 27 (32) Other 9 (11) Did not specify 2 (2.4) Who is primarily responsible for your patients after TIA and ischemic stroke with regard to long-term secondary prevention? Neurologist 22 (26) General practitioner 36 (43) Physician assistant 6 (7.1) The stroke nurse 3 (3.6) The internist 1 (1.2) Other 12 (14) No one is primarily responsible 4 (4.8) Who, in your opinion, should ideally be responsible for patients after TIA and ischemic stroke with regard to long-term secondary prevention? Neurologist 21 (25) General practitioner 42 (50) Physician assistant 6 (7.1) The stroke nurse 7 (8.3) The internist 2 (2.4) Other 6 (7.1) * neurology residency training programs are not limited to academic centers in the Netherlands. 129 _final opmaakbestand.indd :21

6 TABLE 2 Questions regarding pharmacological treatment for patients after TIA or ischemic stroke n (%) C H A P T E R 8 : P R A C T I C E V A R I A T I O N I N L O N G - T E R M S E C O N D A R Y S T R O K E P R E V E N T I O N I N T H E N E T H E R L A N D S Do you use clopidogrel monotherapy as first-line antiplatelet agent in long-term secondary stroke prevention, instead of the combination aspirin/dipyridamol? Always 10 (12) Usually 11 (13) Sometimes 57 (68) Never 6 (7.1) Have you prescribed a NOAC in the past year? Yes 21 (25) No 63 (75) Do you initiate antihypertensive therapy for long-term secondary stroke prevention? Always 9 (11) Usually 28 (33) Sometimes 37 (44) Never 10 (12) Which blood pressure target level do you aim for? The lower, the better 12 (14) 140/90 mm Hg for all 22 (26) 140/90 mm Hg, 130/80 mmhg for patients with diabetes 15 (18) 130/80 mm Hg for all 19 (23) Other 8 (9.5) Did not specify 10 (12) Do you prescribe antihypertensive therapy in normotensive patients? Always 1 (1.2) Usually 10 (12) Sometimes 29 (35) Never 34 (40) Did not specify 10 (12) Do you initiate lipid-lowering therapy for long-term secondary stroke prevention? Always 53 (63) Usually 25 (30) Sometimes 5 (6.0) Never 1 (1.2) Do you routinely assess LDL cholesterol levels after initiating statin therapy? Yes 34 (40) No 49 (58) Did not specify 1 (1.2) Which LDL-cholesterol target level do you aim for? No target 17 (20) <100 mg/dl 51 (61) <70 mg/dl 8 (9.5) Depending on stroke subtype 2 (2.4) Other 5 (6.0) Did not specify 1 (1.2) 130 NOAC = New oral anticoagulant _final opmaakbestand.indd :21

7 TABLE 3 Questions regarding non-pharmacological strategies for patients after TIA or ischemic stroke: Do you systematically discuss the following lifestyle risk factors with patients after TIA or ischemic stroke? Always Usually Sometimes Never Tobacco use 74 (88%) 10 (11%) 0 0 Heavy alcohol use 45 (53%) 22 (26%) 16 (19%) 1 (1.2%) Physical inactivity 35 (41%) 34 (40%) 14 (16%) 1 (1.2%) Unhealthy diet 30 (35%) 29 (34%) 20 (23%) 5 (6.0%) Non-adherence to medication 35 (41%) 25 (29%) 21 (25%) 3 (3.6%) assistants (31%), and stroke nurses (32%). Table 1 details responses to questions regarding the organization of outpatient care for TIA and ischemic stroke patients. Twenty-two (26%) respondents stated that the neurologist is primarily responsible for long-term secondary prevention for TIA and ischemic stroke patients after initial hospital assessment, 36 (43%) reported that the general practitioner is primarily responsible, 6 (7.1%) the physician assistant, 3 (3.6%) the stroke nurse, 1 (1.2%) the internist, and 4 (4.8%) reported that no one is primarily responsible. Regarding who ideally should be responsible for long-term secondary prevention after TIA and ischemic stroke, 42 (50%) respondents answered the general practitioner, 21 (25%) the neurologist, 7 (8.3%) the stroke nurse, 6 (7.1%) the physician assistant, 2 (2.4%) the internist, and 6 (7.1%) preferred a combination of either the neurologist and the general practitioner or the latter and the stroke nurse. Phar macological Treatment for Long-ter m Secondary Stroke Prevention Overall, 75 (89%) respondents reported that the pharmacologic treatment for TIA and ischemic stroke patients is described in a local protocol. Ten (12%) respondents use clopidogrel monotherapy as first-line antiplatelet agent in secondary stroke prevention, instead of the in the Netherlands recommended combination of acetylsalicylic acid and dipyridamole (Table 2). Among those respondents who did usually (13%) or sometimes (68%) use clopidogrel in secondary 131 _final opmaakbestand.indd :21

8 C H A P T E R 8 : P R A C T I C E V A R I A T I O N I N L O N G - T E R M S E C O N D A R Y S T R O K E P R E V E N T I O N I N T H E N E T H E R L A N D S stroke prevention, the most common reason cited were side effects of acetylsalicylic acid or dipyridamole (66%). Other reported reasons included recurrent TIA or ischemic stroke while on acetylsalicylic acid and dipyridamole (20%), acetylsalicylic acid resistance (13%), similarity in efficacy to aspirin and dipyridamole (9.5%), ease of administration (9.5%), and low costs (7.1%). When asked whether they used new oral anticoagulants as long-term secondary stroke prevention for patients with atrial fibrillation during the last year, 21 (25%) respondents reported that they did. Most respondents (83%) stated that they are planning to prescribe new oral anticoagulants in the near future. Eleven percent of respondents reported that they always initiate antihypertensive therapy for secondary stroke prevention in patients with high blood pressure. On the contrary, 10 (12%) respondents never initiate anti-hypertensive therapy for secondary stroke prevention. Most respondents usually (33%) or sometimes (44%) initiate antihypertensive therapy for secondary stroke prevention in patients with high blood pressure. The most frequently prescribed antihypertensive agents were angiotensin-converting enzyme inhibitors (71%) and diuretics (63%). Less commonly used antihypertensive agents were calcium channel blockers (26%), angiotensin receptor blockers (17%), and beta blockers (13%). More than one third (38%) of the respondents use 2 antihypertensive agents in fixed dose combinations if indicated. The blood pressure targets reported were variable, 22 (26%) respondents use a target of 140/90 mm Hg or less for all patients, 19 (23%) respondents use a target of 130/80 m mhg or less for all patients, and 15 (18%) respondents use a target of 140/90 mm Hg or less or 130/80 mm Hg or less for patients with diabetes mellitus. Only the minority of the respondents always (1.2%) or usually (12%) prescribe antihypertensive agents in normotensive stroke patients. Fiftyfive (66%) of the respondents take patient age into account when prescribing antihypertensive agents. In total, 53 (63%) of respondents stated that they always start a statin for secondary stroke prevention. A total of 34 (40%) respondents 132 _final opmaakbestand.indd :21

9 reported that they check their patients low-density lipoprotein cholesterol (LDL-C) levels routinely. Most (70%) respondents use a treat to target strategy, 51 (61%) use an LDL-C target level of less than 100 mg/dl (< 2.5 mmol/l), and 8 (9.5%) use a level of less than 70 mg/dl (< 1.8 mmol/l). Seventeen (20%) respondents do not use a specific LDL-C target, and 2 (2.4%) respondents use an LDL-C target depending on the ischemic stroke subtype. More than half of the respondents take patient age into account when deciding whether statin prescription is indicated. Nonphar macologic Strategies for Long-ter m Secondary Stroke Prevention Overall, 42 (50%) of the respondents stated that the nonpharmacologic treatment for long-term secondary stroke prevention, regarding lifestyle risk factors, is described in a local protocol. The assessment and documentation of the lifestyle risk factors are variable. Nearly all respondents systematically ask for and document tobacco use (99%) and alcohol use (98%), if applicable. Less systematically body weight (68%), body mass index (42%), physical inactivity (42%), unhealthy diet (23%), and waist circumference (6.0%) are asked for and documented. Forty-four (52%) respondents always deliver lifestyle modification advice to TIA and ischemic stroke patients. Overall, 74 (88%) respondents always and 10 (12%) respondents usually discuss the importance of smoking cessation in secondary stroke prevention. The other lifestyle risk factors are less systematically addressed (Table 3). Discussion As hypothesized, we found considerable practice variation in longterm secondary stroke prevention among Dutch neurologists. We found considerable variation in the organization of outpatient care after initial hospital assessment, pharmacologic treatments, and 133 _final opmaakbestand.indd :21

10 C H A P T E R 8 : P R A C T I C E V A R I A T I O N I N L O N G - T E R M S E C O N D A R Y S T R O K E P R E V E N T I O N I N T H E N E T H E R L A N D S nonpharmacologic strategies. To our knowledge, this is the first study investigating practice variations in long-term secondary stroke prevention. Although nearly all respondents reported that they follow-up TIA and ischemic stroke patients after initial hospital assessment, the type of health care workers who delivered the care, the number of follow-up visits, and follow-up duration were highly variable. There was also considerable disagreement among the respondents on who ideally should be responsible for long-term secondary prevention after TIA and ischemic stroke. Half of the respondents stated that the general practitioner should primarily be responsible for long-term secondary stroke prevention, whereas the other half of the respondents favored a hospital-based strategy. To date, it is unclear who is best suited to coordinate cardiovascular risk management for TIA and ischemic stroke patients, and further studies are needed on this topic. Irrespectively of who is or should be responsible for long-term secondary prevention after TIA and ischemic stroke, all involved health-care professionals should in our opinion work in a coordinated manner and attempt to reach a targeted standard of care. Therefore, a close collaboration between primary and secondary care is of paramount importance. Since the results of the Profess trial, which showed similar rates of stroke recurrence with the combination of acetylsalicylic acid and dipyridamole compared with clopidogrel, the latter is a convenient alternative for antithrombotic therapy. 16 This is in accordance with daily practice as in our survey 12% of respondents always and 13% usually prescribe clopidogrel monotherapy. Most of the (remaining) respondents answered that they sometimes prescribe clopidogrel in secondary stroke prevention. It seems that, although the combination of acetylsalicylic acid and dipyridamole still is the first-line antithrombotic therapy for secondary stroke prevention in the Netherlands, the use of clopidogrel monotherapy is increasing. Together with the use of antihypertensive agents in fixed dose combinations, this will improve medication adherence in TIA and ischemic stroke patients _final opmaakbestand.indd :21

11 This survey shows there is considerable variation in blood pressure treatment targets. Most respondents use a blood pressure target of 140/90 mm Hg or less or 130/80 mm Hg or less for all patients. This variation could possibly be explained by the lack of an absolute target blood pressure level in international ischemic stroke guidelines, although the Dutch guideline for cardiovascular risk management advises a blood pressure target of 140/90 mm Hg or less for patients with cardiovascular disease. In addition, it is remarkable that although national and international guidelines recommend starting blood pressure lowering therapy regardless the initial blood pressure, only 1 (1.2%) respondent always and 10 (12%) respondents usually commence blood pressure lowering therapy in normotensive TIA or ischemic stroke patients A similar variation in treatment targets was found regarding lipidlowering therapy for secondary stroke prevention. Although 53 (63%) respondents always and 25 (30%) respondents usually commence lipid-lowering therapy, only 51 (61%) respondents use the national guideline recommended LDL-C target of less than 100 mg/dl A possible explanation for this variation could be the unclear association between LDL-C levels and stroke risk in TIA and ischemic stroke patients. Until now, studies comparing normal versus intensive LDL-C lowering strategies in patients after TIA or ischemic stroke are lacking. This may have resulted in the fact that a substantial part of the neurologists prescribe statins to ischemic stroke patients without aiming for a specific LDL-C level. Half of the respondents reported that treatment regarding lifestyle modification advice is described in a local protocol. Most respondents always inform their TIA and ischemic stroke patients about the importance of smoking cessation. There is considerably less attention for the other lifestyle risk factors. Again, these results are in contrast with the targeted standard of care in national and international guidelines Thus, regarding lifestyle modification, there is still much to be gained. To improve health behavior (ie, physical activity, 135 _final opmaakbestand.indd :21

12 C H A P T E R 8 : P R A C T I C E V A R I A T I O N I N L O N G - T E R M S E C O N D A R Y S T R O K E P R E V E N T I O N I N T H E N E T H E R L A N D S medication adherence, cessation of smoking, moderate alcohol intake, and healthy eating), we find that effective behavior change interventions, for example, motivational interviewing, need to be incorporated in routine clinical practice for TIA and ischemic stroke patients. 18 Comprehensive cardiac rehabilitation programs, including a physical exercise program, reduce mortality in patients after myocardial infarction. 19 Although TIA, ischemic stroke, and myocardial infarction share risk factors and pathologic mechanisms, a specific rehabilitation program to improve cardiorespiratory fitness, to influence secondary prevention targets, and to systematically address cardiovascular lifestyle targets has not been implemented for TIA or ischemic stroke patients. Improving adherence to guidelines and cardiovascular lifestyle changes by standardizing poststroke care, mirroring practice in cardiac rehabilitation programs, could be a promising method for increasing effectiveness of secondary stroke prevention. The strength of this study lies in the high response rate (93%) and the fact that it was a relatively large sample of Dutch neurologists, covering nearly all Dutch Hospitals. Our study has some limitations. First, a problem inherent to an online survey is that management as reported in a questionnaire does not always reflect actual practice. Despite the high response rate of our online survey, participating stroke neurologists were not necessarily representative for the local policy. Second, because this survey does not measure the quality of care, it is not possible to determine which approach to long-term secondary prevention reduces recurrent stroke and other cardiovascular disease most. Third, because all Dutch inhabitants have an assigned general practitioner who treats chronic illnesses, including cardiovascular diseases, quality of stroke care may be better than what is perceived in this survey. Because of these factors, care must be taken into extrapolating the results. In the Netherlands, currently 136 _final opmaakbestand.indd :21

13 a national database, developed by a national knowledge-based network for stroke professionals Kennisnetwerk CVA Nederland has been developed and is being implemented in collaboration with the Dutch Institute for Clinical Auditing, in which baseline variables and functional outcome at 3 months after stroke will be prospectively assessed, enabling evaluation and prognostification of stroke care in the future. In conclusion, our survey shows considerable variation in long-term secondary stroke prevention among Dutch neurologists. These variations may have an impact on the risk for stroke recurrence and cardiovascular disease in general. Further studies are needed to address this issue and to detect possible causes for the gap between guideline recommendations and routine clinical practice, to eventually improve quality of care for TIA and ischemic stroke patients. Acknowledgment The authors would like to thank all respondents of the survey for participation. The authors would like to thank Ms. G.M. McLean for her contribution to the article. 137 _final opmaakbestand.indd :21

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