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Knowledge Gaps in Stroke Care: Results of a Survey of Family Physicians in Pakistan
Knowledge Gaps in Stroke Care: Results of a Survey of Family Physicians in Pakistan Mohammad Wasay, MD, FRCP, FAAN,* Bhojo Khealani, FCPS,* Adnan Yousuf, MBBS,* Iqbal Azam, MSc,* Suresh L. Rathi, MBBS,x Abdul Malik, MBBS, DCN,† and Anwar Haq, FRCP‡
Family physicians play a pivotal role in stroke prevention (primary and secondary) and early management of stroke in developing countries. The objective of this study was to evaluate whether Pakistani family physicians’ approach to stroke prevention and management was in accordance with established international guidelines. This was a cross-sectional survey of randomly selected family physicians in Pakistan, conducted in 2007. A total of 588 family physicians participated in the study. The data reveal that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly idenitfy all 5 symptoms; 93% of the physicians check blood pressure in their adult patients regularly, and 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 90% ask their patients about cigarette smoking or tobacco use, but only 64% regularly advise their patients to quit smoking; 75% do not routinely check cholesterol levels in their patients; 36% treat patients with stroke by themselves, whereas 64% prefer to refer these patients to a specialist or hospital; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure .160/100 mm Hg; and 95% use antiplatelet agents for stroke prevention, with 70% using aspirin and 28% using clopidogrel as first-line antiplatelet therapy. These data indicate a substantial gap between international guidelines and Pakistani family physicians’ management of stroke patients. There is an urgent need for stroke-related continuing medical education to propagate stroke management guidelines. Key Words: Treatment—physicians—developing country. Ó 2011 by National Stroke Association
From the *Department of Neurology and Community Health Sciences, Aga Khan University, Karachi, Pakistan; †Department of Neurology, Liaquat National Hospital, Karachi, Pakistan; ‡Department of Neurology, Peshawar Medical College, Peshawar, Pakistan; and xDepartment of Medicine, Isra University, Hyderabad, Pakistan. Received August 18, 2009; accepted January 4, 2010. These findings were presented in preliminary form at the 60th Annual meeting of the American Academy of Neurology, Chicago, April 2008. Supported by a grant from the Pakistan Stroke Society. The authors declare no conflicts of interest. Address correspondence to Mohammad Wasay MD, FRCP, FAAN, Department of Medicine/Neurology, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.; E-mail: mohammad.wasay@aku. edu; [email protected]. 1052-3057/$ - see front matter Ó 2011 by National Stroke Association doi:10.1016/j.jstrokecerebrovasdis.2010.01.010
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The burden of stroke is likely to grow in Pakistan, reflecting the very high prevalence of risk factors. The 1998 Pakistan National Health Survey revealed that 33% of the Pakistani population above age 45 has hypertension.1 Pakistan currently ranks sixth worldwide in terms of diabetes prevalence,2 with 5.2 million diabetic persons in 2000. This number is projected to rise to 13.9 million by 2020, which will raise Pakistan’s rank to fourth.3 According to the National Health Survey of Pakistan, 25% of the population above age 45 years has diabetes mellitus.1 The reported prevalence of smoking is 14%-21% in Pakistani adolescents and adults.4 The high prevalence of rheumatic heart disease (approximately 6/1000) also may be an important risk factor for stroke.5 Currently, there are only about 150 trained neurologists in Pakistan for a population of 165 million (translating to 1
Journal of Stroke and Cerebrovascular Diseases, Vol. 20, No. 4 (July-August), 2011: pp 282-286
STROKE KNOWLEDGE GAPS IN A DEVELOPING COUNTRY
neurologist for 1.1 million people). Most patients with stroke do not have access to a neurologist and are treated by internists and family physicians. The primary prevention of stroke depends mainly on family physicians. A recent study from Pakistan concluded that family physicians underdiagnose and undertreat high blood pressure.6 This study also found that .70% of patients with high blood pressure are unaware of their disease despite regular visits to a physician.6 Cardiovascular risk factors coupled with stroke are increasing in developing countries, especially those in the Indian subcontinent.7 The high prevalence of these risk factors is further aggravated by the alarmingly poor awareness by both community and family physicians. Established guidelines for primary and secondary stroke prevention and acute and long-term stroke management8-10 as recommended by the American Heart Association (AHA) and American Stroke Association (ASA) are generally accepted throughout the world, including Pakistan. Knowledge of these guidelines and application of these guidelines in clinical practice is vital to controlling the growing epidemic of stroke in Pakistan. Studies have indicated a substantial gap between guidelines and practice even in developed countries. For example, an Italian survey of family physician revealed that antiplatelets or anticoagulants were prescribed to only 72% of patients with stroke or transient ischemic attack.11 Similarly, a report from the Netherlands showed that 41% of stroke patients received suboptimal care by general practitioners, mainly in terms of hypertension control.12 Data from 2 large Canadian registries with inclusion criteria of coronary artery disease, peripheral vascular disease, and/or stroke revealed that only 78% of the patients received antiplatelet agents and only 75% received statins.13,14 A recent analysis of studies evaluating the gap between evidence and practice revealed that 25% of physicians reported a lack of knowledge, awareness, or skills as a barrier to providing optimal care.15 Because practice patterns of Pakistani family physicians related to stroke prevention and treatment are unknown, and a lack of knowledge/ awareness is an important factor hindering evidencebased optimal health care, assessing the knowledge of our general practitioners to determine the gap between stroke guidelines and their practice is important to provide opportunities for continuing professional development of family physicians, fill gaps in their knowledge, and ultimately improve the care of stroke patients in Pakistan. The present study was a cross-sectional survey of family physicians in Pakistan designed to assess their knowledge regarding symptoms of stroke, risk factors for stroke, treatment of acute stroke, primary and secondary prevention, and their current practices in this regard. The survey also included questions regarding the physicians’
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practice type, years of practice, and resources available for updating their knowledge.
Methods A team of neurologists developed a questionnaire in English. The self-administered questionnaire was pretested in a pilot study and was revised to optimize the response rate and reduce the number of irrelevant items. The questionnaire was mailed to nominated neurologists in all 4 provinces of Pakistan, who headed teams of research officers who conducted the random survey in major cities of these provinces. The final questionnaire contained 24 items to elicit information on (1) physician practice (eg, place of practice, practice setting [teaching vs nonteaching], average number of patients seen daily, year of graduation from medical school), (2) knowledge of stroke and its risk factors (eg, symptoms of acute stroke; risk factors for stroke, including inquiry about smoking on every visit; and frequency of BP monitoring) (3) assessment of stroke (eg, next step in management of patients presenting with stroke, preferred medications, triage of patients with questionable diagnoss), (4) knowledge of and adherence to current AHA stroke guidelines and preventive strategies (eg, antiplatelet drugs for stroke prevention, cutoff value in treating high blood pressure in patients age .55 years, most commonly used antihypertensive medications for stroke patients, target fasting cholesterol level for patients sustaining stroke in the previous year) and (5) sources used to update their knowledge regarding stroke (eg, seminars, lectures, medical journals). In calculating the sample size for the physician survey of compliance with guidelines, 75% were expected to follow the guidelines, with a error bound of 0.04 (4%) with 2 pq 95% confidence interval, (Zða=2Þ ); the maximum sample B2 size was found to be 451. Accounting for a nonresponse rate of about 10%, the minimum sample size required was approximately 496. This cross-sectional study of licensed family physicians in Pakistan was conducted in all 4 major provinces in both urban and rural areas during 2007. The study population comprised all physicians licensed by the Pakistan Medical and Dental Council (PMDC). A total of 112,000 physicians (with a basic degree, ie, MBBS only) were registered by the PMDC at the time of the study; about half of these (about 55,000) are involved in general practice (ie, working as family physicians). (www.pmdc.org.pk) A sample of 700 physicians was randomly selected from this list of family physicians and general practitioners; of these, 588 physicians consented to participate in the study. Each family physician was visited by a trained research officer, who administered the standardized questionnaire after obtaining verbal consent. The questionnaire was designed to be completed in 10-15 minutes. The study design was approved by the Ethics Review Committee of Aga Khan University.
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Results Of the 700 family physicians contacted, 588 (84%) consented to participate in the study. These 588 physicians included 403 men (69%) and 155 women (31%). Of these 588 physicians, 242 (41%) were affiliated with hospitals (107 in government hospitals, 80 in private hospitals, and 55 in teaching hospitals), and 346 (59%) worked as independent family physicians. These physicians were seeing an average of 39 adult patients every day. Ninety-eight physicians (17%) had graduated from medical college within the previous 5 years; the mean duration since graduation was 15 years (range, 1-49 years). Complete data on age, education, years after graduation, and type of practice were not available for the 112 physicians contacted who refused to participate in the survey. Of these 112 physicians, 85 were men (76%), 68 (61%) were affiliated with a hospital, and 44 (39%) were general practitioners. The survey included blood pressure control and smoking cessation as key indicators for primary stroke prevention. A total of 561 physicians (93%) reported checking their adult patients’ blood pressure routinely. For a 55year-old man with no comorbidities, 373 (61%) physicians used a cutoff of 140/90 mm Hg to start antihypertensive therapy, whereas 109 (18%) used a cutoff of 150/90 mm Hg and 106 (18%) used a cutoff of .160/90 m Hg. Five hundred and forty-five physicians (91%) asked their patients about cigarette smoking, but only 387 (64%) routinely counseled their patients regarding smoking cessation. Four hundred and forty-one (75%) did not routinely check their patients’ cholesterol levels. Although 98% physicians identified hypertension as a risk factor for stroke, only 73% listed diabetes mellitus, 65% listed cigarette smoking, 45% listed high cholesterol, and 27% listed heart disease as an important risk factor for stroke. Only 270 of the physicians (46%) were able to correctly report all 5 common symptoms of acute stroke (hemiparesis, dysarthria, walking difficulty, loss of vision, and vertigo) out of a list of more than 15 symptoms. Of these 5 symptoms, hemiparesis and dysarthria were identified by 90% of the physicians, but walking with difficulty, vertigo, and loss of vision were reported less frequently (Table 1). The majority of physicians identified bilateral leg or bilateral arm weakness as a stroke symptom, and a significant minority identified neck pain and backache as stroke symptoms (Table 1). Two hundred and twelve physicians (36%) treated patients with stroke by themselves, whereas 64% were likely to refer patients to a specialist or hospital. In a setting of acute stroke, 335 physicians (57%) prescribed intravenous or sublingual antihypertensive medications in patients with a blood pressure of $160/100 mm Hg. In this study, the type of antihypertensive medication, use of antiplatelets and statins were indicators for stroke secondary prevention strategy. In patients with stroke, 471 (80%) physicians used a beta blocker, an angiotensin-
Table 1. Common stroke symptoms, as ranked by family physicians Rank
Symptom
Frequency
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Hemiparesis Slurring of speech Paralysis of both legs Paralysis of both arms Inability to walk Vertigo Loss of consciousness Loss of vision in one or both eyes Numbness of whole body Vomiting Neck pain Severe back pain Fits Shortness of breath Chest pain Fever Other
90% 90% 85% 79% 75% 62% 62% 39% 27% 23% 19% 18% 17% 10% 9% 5% 7%
converting enzyme inhibitor, or an angiotensin receptor blocker (alone or in combination) for long-term management of hypertension. A majority of the physicians (ie, 559 [95%]) administered antiplatelet agents for stroke prevention; 391 (70%) used aspirin 157 (28%) used clopidogrel as first-line antiplatelet therapy. Only 259 physicians (44%) prescribed statins for secondary stroke prevention. Questions regarding long-term stroke management were related to the use of physiotherapy, duration of antiplatelet and antihypertensive therapy, and perceptions about stroke recurrence. Only 82 physicians (14%) referred stroke patients for physiotherapy or rehabilitation. More than 90% of physicians continued antihypertensive therapy as a lifelong treatment, but about 50% discontinued antiplatelets and statins after a few years if stroke did not recur. Only 265 physicians (44%) attended a continuing medical education program related to stroke in the previous year, and 319 (53%) reported reading an article related to stroke in a medical journal. Reported resources used for to update knowledge about stroke in the preceding year were medical journals in 50%, interaction with pharmaceutical representatives in 15%, seminars or conferences in 10%, newspaper articles in 10%, and discussions with colleagues in 6%.
Discussion Data from this cross-sectional survey reveal that only 46% of physicians were aware of all 5 common signs and symptoms of acute stroke. This high degree of unawareness is alarming. Because thrombolytic therapy for stroke is beneficial only when delivered within a narrow time window (ie, within 3-4.5 hours of stroke onset), early recognition of stroke symptoms is of critical
STROKE KNOWLEDGE GAPS IN A DEVELOPING COUNTRY
importance. Another important consequence of Pakistani physicians’ poor awareness is their failure to make appropriate changes in management during acute stroke. For example, although aggressive management is desirable to maintain blood pressure under 140/90 mm Hg in nondiabetic patients and under 130/85 mm Hg in diabetic patients, such aggressive treatment during the acute stroke period likely would be detrimental. The consensus view is that medication can be withheld until systolic blood pressure is .220 mm Hg or diastolic blood pressure is .120 mm Hg.9 Another example involves atrial fibrillation (AF); the presence of lone AF may not require anticoagulation therapy, but AF with stroke necessitates long-term anticoagulation to prevent future stroke.16 Disturbingly, a significant number of physicians listed paraparesis, bilateral arm weakness, backache, or neck pain as one the 5 common symptoms of stroke (Table 1). This misperception could result in improper diagnosis or delay in correct diagnosis, as well as misapplication of financial and health care resources. The reported prevalence of hypertension in Pakistanis age $15 years is 19.0% (95% CI, 18.9%-19.1%).17 The 1990-1994 Pakistan National Health Survey revealed that 22% of urban Pakistani population age .15 years, and a third of those age $45 years, had hypertension.1 Joint National Commission (JNC) VII guidelines for blood pressure evaluation and management recommend starting treatment when blood pressure exceeds 140/90 mm Hg.18 Despite the fact that hypertension is common in Pakistan and the availability of clear guidelines for managing hypertension, the disease remains underdiagnosed and undertreated in Pakistan.6 Although almost all of the physicians surveyed listed hypertension as one of the 5 most common stroke risk factors and reported measuring blood pressure routinely, only two-thirds would start antihypertensive medications in patients with blood pressure .140/90, with the rest using a higher cutoff. Diabetes mellitus and coronary artery disease are two important modifiable and prevalent risk factors for stroke. In Pakistan, the reported prevalence of diabetes is 5.4% (95% CI, 4.9%-5.9%) in persons age .15 years19 and 25% in those age .45.1 The reported prevalence of coronary artery disease is 26.9% (95% CI, 2.9%-32%) in persons age 40.3 In this survey, 75% of patients reported diabetes mellitus as one of the 5 most important risk factors for stroke, but only 27% identified coronary artery disease as an important risk factor. Poor awareness of modifiable stroke risk factors results in cursory evaluation and hence suboptimal utilization of secondary stroke prevention strategies. In the present survey, 65% of physicians identified smoking as a common stroke risk factor, but although .90% of the physicians asked their patients about smoking, only 67% routinely advised their patients to quit smoking. This is an important aspect of management; counseling and emotional and pharmacologic support can help some patients quit smoking. Control of risk factors and
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therapy with antiplatelet agents and statins are mainstays of secondary stroke prevention.20 One study reported that 83% of Pakistani stroke patients receive aspirin for secondary stroke prevention, but ,3% receive statins.21 Our survey found that ,50% of the physicians used statins for this purpose, however. Although secondary prevention therapies are considered life-long, half of the physicians in our survey reported stopping antiplatelet medications after 5 years in patents without stroke recurrence. Even more alarming was the poor utilization of rehabilitation and physiotherapy in stroke patients. The results of our survey suggest that Pakistani family physicians’ ability to recognize troke symptoms and knowledge of stroke risk factors are suboptimal. In addition, there is a substantial gap between existing evidencebased guidelines and the actual management of stroke patients. Continuing medical education and promotion of guidelines by institutions and professional societies are necessary to improve the care of stroke patents in Pakistan. New strategies for both research and implementation are needed to help close this treatment gap in Pakistan and other developing countries. Otherwise, the lack of a structured continuous professional development program in stroke management will continue to compromise patient care.
References 1. Pakistan Medical Research Council. National Health Survey of Pakistan, 1990–1994. Islamabad: Pakistan Medical Research Council, 1998. p.49-69. 2. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: Estimates for year 2000 and projection for 2020. Diabetes Care 2004;27:1047-1053. 3. Jafar TH, Jafary FH, Jassani S, et al. Heart disease epidemic in Pakistan: Women and men at equal risk. Am Heart J 2005;150:221-226. 4. Ahmad K, Jafary F, Jehan I, et al. Prevalence and predictors of smoking in Pakistan: Results of the National Health Survey of Pakistan. Eur J Cardiovasc Prev Rehabil 2005;12:203-208. 5. Rizvi SF, Khan MA, Kundi A, et al. Status of rheumatic heart disease in rural Pakistan. Heart 2004;90:394-399. 6. Jafar TH, Jessani S, Jafar FH, et al. General practitioners’ approach to hypertension in urban Pakistan: Disturbing trends in practice. Circulation 2005;111:1278-1283. 7. Bulatao RA, Stephens PW. Global Estimates and Projections of Mortality by Cause. Washington, DC: World Bank, Population, Health and Nutrition Department, 1992. 1007. 8. Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: A guideline from American Heart Association/American Stroke Association Stroke Council, cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group, Cardiovascular Nursing Counsel, Clinical Cardiology Council; Nutrition Physical Activity and Metabolism Council, and the Quality of Care and Outcome Research Interdisciplinary Working Group. Stroke 2006;37:1583-1633. 9. Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke:
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10.
11.
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A guideline from the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research interdisciplinary working groups. Stroke 2007;38: 1655-1711. Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendation for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke 2008;39:1647-1652. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendation for stroke survivors: An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation 2004;109:2031-2041. Filippi A, Bignamini AA, Sessa E, et al. Secondary prevention of stroke in Italy: A cross-sectional survey in family practice. Stroke 2003;34:1010-1014. De Koning JS, Lazing NS, Koudstaal PJ, et al. Quality of care in stroke prevention: Results of an audit study among general practitioners. Prev Med 2004;38:129-136.
14. Tsang JLY, Mendelsohn A, Tan MK, et al. Discordance between physician’s estimation of patient cardiovascular risk and use of evidence-based medical therapy. Am J Cardiol 2008;102:1142-1145. 15. Cochrane LJ, Olson CA, Murray S, et al. Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care. J Contin Edu Health Prof 2007;27:94-102. 16. Lip GYH, Lim HS. Atrial fibrillation and stroke prevention. Lancet Neurol 2007;6:981-993. 17. Jafar TH, Levey AS, Jafary TH, et al. Ethinic subgroups differences in hypertension in Pakistan. J Hypertens 2003; 21:905-912. 18. Chobanian AV, Bakris GI, Black HR, et al. National High Blood Pressure Education Program Coordinating Committee. JAMA 2003;289:2560-2572. 19. Jafar TH, Levey AS, White FM, et al. Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan. Diabetes Med 2004;21:716-723. 20. O’Regan C, Wu P, Arora P, et al. Statin therapy in stroke prevention: A meta-analysis involving 121,000 patients. Am J Med 2008;121:24-33. 21. Medis S, Abegunde D, Yusuf S, et al. WHO-PREMISE Study (Phase I) Study Group. Bull World Health Organ 2005;83:820-828.
Family physicians play a pivotal role in stroke prevention (primary and secondary) and early management of stroke in developing countries. The objective of this study was to evaluate whether Pakistani family physicians’ approach to stroke prevention and management was in accordance with established international guidelines. This was a cross-sectional survey of randomly selected family physicians in Pakistan, conducted in 2007. A total of 588 family physicians participated in the study. The data reveal that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly idenitfy all 5 symptoms; 93% of the physicians check blood pressure in their adult patients regularly, and 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 90% ask their patients about cigarette smoking or tobacco use, but only 64% regularly advise their patients to quit smoking; 75% do not routinely check cholesterol levels in their patients; 36% treat patients with stroke by themselves, whereas 64% prefer to refer these patients to a specialist or hospital; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure .160/100 mm Hg; and 95% use antiplatelet agents for stroke prevention, with 70% using aspirin and 28% using clopidogrel as first-line antiplatelet therapy. These data indicate a substantial gap between international guidelines and Pakistani family physicians’ management of stroke patients. There is an urgent need for stroke-related continuing medical education to propagate stroke management guidelines. Key Words: Treatment—physicians—developing country. Ó 2011 by National Stroke Association
From the *Department of Neurology and Community Health Sciences, Aga Khan University, Karachi, Pakistan; †Department of Neurology, Liaquat National Hospital, Karachi, Pakistan; ‡Department of Neurology, Peshawar Medical College, Peshawar, Pakistan; and xDepartment of Medicine, Isra University, Hyderabad, Pakistan. Received August 18, 2009; accepted January 4, 2010. These findings were presented in preliminary form at the 60th Annual meeting of the American Academy of Neurology, Chicago, April 2008. Supported by a grant from the Pakistan Stroke Society. The authors declare no conflicts of interest. Address correspondence to Mohammad Wasay MD, FRCP, FAAN, Department of Medicine/Neurology, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.; E-mail: mohammad.wasay@aku. edu; [email protected]. 1052-3057/$ - see front matter Ó 2011 by National Stroke Association doi:10.1016/j.jstrokecerebrovasdis.2010.01.010
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The burden of stroke is likely to grow in Pakistan, reflecting the very high prevalence of risk factors. The 1998 Pakistan National Health Survey revealed that 33% of the Pakistani population above age 45 has hypertension.1 Pakistan currently ranks sixth worldwide in terms of diabetes prevalence,2 with 5.2 million diabetic persons in 2000. This number is projected to rise to 13.9 million by 2020, which will raise Pakistan’s rank to fourth.3 According to the National Health Survey of Pakistan, 25% of the population above age 45 years has diabetes mellitus.1 The reported prevalence of smoking is 14%-21% in Pakistani adolescents and adults.4 The high prevalence of rheumatic heart disease (approximately 6/1000) also may be an important risk factor for stroke.5 Currently, there are only about 150 trained neurologists in Pakistan for a population of 165 million (translating to 1
Journal of Stroke and Cerebrovascular Diseases, Vol. 20, No. 4 (July-August), 2011: pp 282-286
STROKE KNOWLEDGE GAPS IN A DEVELOPING COUNTRY
neurologist for 1.1 million people). Most patients with stroke do not have access to a neurologist and are treated by internists and family physicians. The primary prevention of stroke depends mainly on family physicians. A recent study from Pakistan concluded that family physicians underdiagnose and undertreat high blood pressure.6 This study also found that .70% of patients with high blood pressure are unaware of their disease despite regular visits to a physician.6 Cardiovascular risk factors coupled with stroke are increasing in developing countries, especially those in the Indian subcontinent.7 The high prevalence of these risk factors is further aggravated by the alarmingly poor awareness by both community and family physicians. Established guidelines for primary and secondary stroke prevention and acute and long-term stroke management8-10 as recommended by the American Heart Association (AHA) and American Stroke Association (ASA) are generally accepted throughout the world, including Pakistan. Knowledge of these guidelines and application of these guidelines in clinical practice is vital to controlling the growing epidemic of stroke in Pakistan. Studies have indicated a substantial gap between guidelines and practice even in developed countries. For example, an Italian survey of family physician revealed that antiplatelets or anticoagulants were prescribed to only 72% of patients with stroke or transient ischemic attack.11 Similarly, a report from the Netherlands showed that 41% of stroke patients received suboptimal care by general practitioners, mainly in terms of hypertension control.12 Data from 2 large Canadian registries with inclusion criteria of coronary artery disease, peripheral vascular disease, and/or stroke revealed that only 78% of the patients received antiplatelet agents and only 75% received statins.13,14 A recent analysis of studies evaluating the gap between evidence and practice revealed that 25% of physicians reported a lack of knowledge, awareness, or skills as a barrier to providing optimal care.15 Because practice patterns of Pakistani family physicians related to stroke prevention and treatment are unknown, and a lack of knowledge/ awareness is an important factor hindering evidencebased optimal health care, assessing the knowledge of our general practitioners to determine the gap between stroke guidelines and their practice is important to provide opportunities for continuing professional development of family physicians, fill gaps in their knowledge, and ultimately improve the care of stroke patients in Pakistan. The present study was a cross-sectional survey of family physicians in Pakistan designed to assess their knowledge regarding symptoms of stroke, risk factors for stroke, treatment of acute stroke, primary and secondary prevention, and their current practices in this regard. The survey also included questions regarding the physicians’
283
practice type, years of practice, and resources available for updating their knowledge.
Methods A team of neurologists developed a questionnaire in English. The self-administered questionnaire was pretested in a pilot study and was revised to optimize the response rate and reduce the number of irrelevant items. The questionnaire was mailed to nominated neurologists in all 4 provinces of Pakistan, who headed teams of research officers who conducted the random survey in major cities of these provinces. The final questionnaire contained 24 items to elicit information on (1) physician practice (eg, place of practice, practice setting [teaching vs nonteaching], average number of patients seen daily, year of graduation from medical school), (2) knowledge of stroke and its risk factors (eg, symptoms of acute stroke; risk factors for stroke, including inquiry about smoking on every visit; and frequency of BP monitoring) (3) assessment of stroke (eg, next step in management of patients presenting with stroke, preferred medications, triage of patients with questionable diagnoss), (4) knowledge of and adherence to current AHA stroke guidelines and preventive strategies (eg, antiplatelet drugs for stroke prevention, cutoff value in treating high blood pressure in patients age .55 years, most commonly used antihypertensive medications for stroke patients, target fasting cholesterol level for patients sustaining stroke in the previous year) and (5) sources used to update their knowledge regarding stroke (eg, seminars, lectures, medical journals). In calculating the sample size for the physician survey of compliance with guidelines, 75% were expected to follow the guidelines, with a error bound of 0.04 (4%) with 2 pq 95% confidence interval, (Zða=2Þ ); the maximum sample B2 size was found to be 451. Accounting for a nonresponse rate of about 10%, the minimum sample size required was approximately 496. This cross-sectional study of licensed family physicians in Pakistan was conducted in all 4 major provinces in both urban and rural areas during 2007. The study population comprised all physicians licensed by the Pakistan Medical and Dental Council (PMDC). A total of 112,000 physicians (with a basic degree, ie, MBBS only) were registered by the PMDC at the time of the study; about half of these (about 55,000) are involved in general practice (ie, working as family physicians). (www.pmdc.org.pk) A sample of 700 physicians was randomly selected from this list of family physicians and general practitioners; of these, 588 physicians consented to participate in the study. Each family physician was visited by a trained research officer, who administered the standardized questionnaire after obtaining verbal consent. The questionnaire was designed to be completed in 10-15 minutes. The study design was approved by the Ethics Review Committee of Aga Khan University.
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Results Of the 700 family physicians contacted, 588 (84%) consented to participate in the study. These 588 physicians included 403 men (69%) and 155 women (31%). Of these 588 physicians, 242 (41%) were affiliated with hospitals (107 in government hospitals, 80 in private hospitals, and 55 in teaching hospitals), and 346 (59%) worked as independent family physicians. These physicians were seeing an average of 39 adult patients every day. Ninety-eight physicians (17%) had graduated from medical college within the previous 5 years; the mean duration since graduation was 15 years (range, 1-49 years). Complete data on age, education, years after graduation, and type of practice were not available for the 112 physicians contacted who refused to participate in the survey. Of these 112 physicians, 85 were men (76%), 68 (61%) were affiliated with a hospital, and 44 (39%) were general practitioners. The survey included blood pressure control and smoking cessation as key indicators for primary stroke prevention. A total of 561 physicians (93%) reported checking their adult patients’ blood pressure routinely. For a 55year-old man with no comorbidities, 373 (61%) physicians used a cutoff of 140/90 mm Hg to start antihypertensive therapy, whereas 109 (18%) used a cutoff of 150/90 mm Hg and 106 (18%) used a cutoff of .160/90 m Hg. Five hundred and forty-five physicians (91%) asked their patients about cigarette smoking, but only 387 (64%) routinely counseled their patients regarding smoking cessation. Four hundred and forty-one (75%) did not routinely check their patients’ cholesterol levels. Although 98% physicians identified hypertension as a risk factor for stroke, only 73% listed diabetes mellitus, 65% listed cigarette smoking, 45% listed high cholesterol, and 27% listed heart disease as an important risk factor for stroke. Only 270 of the physicians (46%) were able to correctly report all 5 common symptoms of acute stroke (hemiparesis, dysarthria, walking difficulty, loss of vision, and vertigo) out of a list of more than 15 symptoms. Of these 5 symptoms, hemiparesis and dysarthria were identified by 90% of the physicians, but walking with difficulty, vertigo, and loss of vision were reported less frequently (Table 1). The majority of physicians identified bilateral leg or bilateral arm weakness as a stroke symptom, and a significant minority identified neck pain and backache as stroke symptoms (Table 1). Two hundred and twelve physicians (36%) treated patients with stroke by themselves, whereas 64% were likely to refer patients to a specialist or hospital. In a setting of acute stroke, 335 physicians (57%) prescribed intravenous or sublingual antihypertensive medications in patients with a blood pressure of $160/100 mm Hg. In this study, the type of antihypertensive medication, use of antiplatelets and statins were indicators for stroke secondary prevention strategy. In patients with stroke, 471 (80%) physicians used a beta blocker, an angiotensin-
Table 1. Common stroke symptoms, as ranked by family physicians Rank
Symptom
Frequency
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Hemiparesis Slurring of speech Paralysis of both legs Paralysis of both arms Inability to walk Vertigo Loss of consciousness Loss of vision in one or both eyes Numbness of whole body Vomiting Neck pain Severe back pain Fits Shortness of breath Chest pain Fever Other
90% 90% 85% 79% 75% 62% 62% 39% 27% 23% 19% 18% 17% 10% 9% 5% 7%
converting enzyme inhibitor, or an angiotensin receptor blocker (alone or in combination) for long-term management of hypertension. A majority of the physicians (ie, 559 [95%]) administered antiplatelet agents for stroke prevention; 391 (70%) used aspirin 157 (28%) used clopidogrel as first-line antiplatelet therapy. Only 259 physicians (44%) prescribed statins for secondary stroke prevention. Questions regarding long-term stroke management were related to the use of physiotherapy, duration of antiplatelet and antihypertensive therapy, and perceptions about stroke recurrence. Only 82 physicians (14%) referred stroke patients for physiotherapy or rehabilitation. More than 90% of physicians continued antihypertensive therapy as a lifelong treatment, but about 50% discontinued antiplatelets and statins after a few years if stroke did not recur. Only 265 physicians (44%) attended a continuing medical education program related to stroke in the previous year, and 319 (53%) reported reading an article related to stroke in a medical journal. Reported resources used for to update knowledge about stroke in the preceding year were medical journals in 50%, interaction with pharmaceutical representatives in 15%, seminars or conferences in 10%, newspaper articles in 10%, and discussions with colleagues in 6%.
Discussion Data from this cross-sectional survey reveal that only 46% of physicians were aware of all 5 common signs and symptoms of acute stroke. This high degree of unawareness is alarming. Because thrombolytic therapy for stroke is beneficial only when delivered within a narrow time window (ie, within 3-4.5 hours of stroke onset), early recognition of stroke symptoms is of critical
STROKE KNOWLEDGE GAPS IN A DEVELOPING COUNTRY
importance. Another important consequence of Pakistani physicians’ poor awareness is their failure to make appropriate changes in management during acute stroke. For example, although aggressive management is desirable to maintain blood pressure under 140/90 mm Hg in nondiabetic patients and under 130/85 mm Hg in diabetic patients, such aggressive treatment during the acute stroke period likely would be detrimental. The consensus view is that medication can be withheld until systolic blood pressure is .220 mm Hg or diastolic blood pressure is .120 mm Hg.9 Another example involves atrial fibrillation (AF); the presence of lone AF may not require anticoagulation therapy, but AF with stroke necessitates long-term anticoagulation to prevent future stroke.16 Disturbingly, a significant number of physicians listed paraparesis, bilateral arm weakness, backache, or neck pain as one the 5 common symptoms of stroke (Table 1). This misperception could result in improper diagnosis or delay in correct diagnosis, as well as misapplication of financial and health care resources. The reported prevalence of hypertension in Pakistanis age $15 years is 19.0% (95% CI, 18.9%-19.1%).17 The 1990-1994 Pakistan National Health Survey revealed that 22% of urban Pakistani population age .15 years, and a third of those age $45 years, had hypertension.1 Joint National Commission (JNC) VII guidelines for blood pressure evaluation and management recommend starting treatment when blood pressure exceeds 140/90 mm Hg.18 Despite the fact that hypertension is common in Pakistan and the availability of clear guidelines for managing hypertension, the disease remains underdiagnosed and undertreated in Pakistan.6 Although almost all of the physicians surveyed listed hypertension as one of the 5 most common stroke risk factors and reported measuring blood pressure routinely, only two-thirds would start antihypertensive medications in patients with blood pressure .140/90, with the rest using a higher cutoff. Diabetes mellitus and coronary artery disease are two important modifiable and prevalent risk factors for stroke. In Pakistan, the reported prevalence of diabetes is 5.4% (95% CI, 4.9%-5.9%) in persons age .15 years19 and 25% in those age .45.1 The reported prevalence of coronary artery disease is 26.9% (95% CI, 2.9%-32%) in persons age 40.3 In this survey, 75% of patients reported diabetes mellitus as one of the 5 most important risk factors for stroke, but only 27% identified coronary artery disease as an important risk factor. Poor awareness of modifiable stroke risk factors results in cursory evaluation and hence suboptimal utilization of secondary stroke prevention strategies. In the present survey, 65% of physicians identified smoking as a common stroke risk factor, but although .90% of the physicians asked their patients about smoking, only 67% routinely advised their patients to quit smoking. This is an important aspect of management; counseling and emotional and pharmacologic support can help some patients quit smoking. Control of risk factors and
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therapy with antiplatelet agents and statins are mainstays of secondary stroke prevention.20 One study reported that 83% of Pakistani stroke patients receive aspirin for secondary stroke prevention, but ,3% receive statins.21 Our survey found that ,50% of the physicians used statins for this purpose, however. Although secondary prevention therapies are considered life-long, half of the physicians in our survey reported stopping antiplatelet medications after 5 years in patents without stroke recurrence. Even more alarming was the poor utilization of rehabilitation and physiotherapy in stroke patients. The results of our survey suggest that Pakistani family physicians’ ability to recognize troke symptoms and knowledge of stroke risk factors are suboptimal. In addition, there is a substantial gap between existing evidencebased guidelines and the actual management of stroke patients. Continuing medical education and promotion of guidelines by institutions and professional societies are necessary to improve the care of stroke patents in Pakistan. New strategies for both research and implementation are needed to help close this treatment gap in Pakistan and other developing countries. Otherwise, the lack of a structured continuous professional development program in stroke management will continue to compromise patient care.
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