For those who practice medicine day in and day out-in fact, for anyone who works in healthcare-it can be difficult to find the time to look up from one's desk and ask the question, is my approach still valid?
The pathophysiology of stroke, risk factors, interventions, and identification of at-risk patients are fairly well understood with primary prevention being the focus of care. If you look up from your desk, the world is not where it was a decade ago. Nowhere is this truer than in the treatment of stroke and transient ischemic attack (TIA) in order to improve recovery and prevent stroke recurrence.
The impact of TIA and stroke should also be appreciated for what it is at the patient and caregiver level. To illustrate this impact, we can compare the resources needed to manage stroke on a daily basis compared with the daily care of hypertension. A Canadian study found that patients with hypertension required 134 hours of caregiver help over a 6-month period: an average of less than 45 minutes per day.1 By comparison, patients with stroke, 6 months after the occurrence of stroke, required 4.6 hours a day of caregiver assistance, a difference of approximately 6.5-fold compared with patients with hypertension.2 These numbers alone drive the need to more effectively prevent and treat TIA and stroke.
In this supplement, we cover from the burden of TIA and stroke and the consequences of its persistent underdiagnosis, to the way different governmental organizations and military healthcare providers address the treatment of stroke, and how they compare with private insurers and private hospitals.
Kessler and Thomas focus on the burden of TIA, the frequency of underdiagnosis of TIA, and the degree to which serious risk of morbidity, mortality, and recurrent stroke are associated with TIA.3 Although it is commonly thought of as a "mini-stroke," TIA may in fact confer a greater risk of secondary stroke than stroke itself.4 The consequences of underdiagnosis and undertreatment of a TIA can be seen in the 10% to 20% risk of secondary stroke within 90 days of a TIA.4-6 The downstream effect of TIA and its sequelae result in a vast burden in mortality, loss of quality of life, and increased healthcare costs.7-11 Prompt and appropriate treatment of TIA can reduce the risk of secondary stroke by 80%.12
For all of the efforts that go into creating and disseminating clinical guidelines, the mechanisms for their implementation are frequently absent. Steven Singh examines a major provider of healthcare in this country that has had better success than most in preventing stroke in TIA and stroke patients: the Veterans Administration (VA).13 Why have they been more successful? They published their own clinical guidelines, and then they expected physicians within their system to adhere to them. To ensure this, they have been measuring adherence to guidelines. The VA carries this a step farther by incentivizing their physicians on quality of care and adherence to the treatment guidelines rather than the more conventional incentives that may not specifically reward patient outcomes. The proof of the VA's success is a better reduction of mortality rates, hospitalization rates, and risk of secondary stroke among their stroke and TIA patients compared with Medicare and Medicaid, and has also been shown to perform better than university hospitals.14-17
Philip Gorelick tackles the rather mixed success of Medicare and Medicaid in the stroke/TIA population and suggests that greater adherence to evidence-based treatment improves patient outcomes and lowering the burden of mortality and cost.18 The size of the Medicare and Medicaid treatment population, and the fact that they represent a particularly at-risk group of patients, means that any positive systemic changes, even relatively small ones, could have an enormous impact on the TIA/stroke treatment landscape. States such as New York and Michigan have taken the initiative to improve TIA and stroke treatment, and in both cases they have significantly increased the prescribing of antithrombotic medications at hospital discharge.19,20 The Centers for Medicare & Medicaid Services has taken the first step in doing so with the introduction of the voluntary Physician Quality Reporting Initiative program, which applies National Committee for Quality Assurance-recommended measures for diagnosis, acute treatment, and discharge in stroke and TIA.
TIA is a subclinical condition and significant risk factor for stroke and should be treated as seriously as if it were a stroke. This means bringing to bear the diagnostic and acute treatment options that have been shown to lower the risk of subsequent stroke or TIA. Follow-up treatment and comorbidities must be dealt with aggressively. Hypertension, diabetes, chronic obstructive pulmonary disease, myocardial infarction, smoking, obesity, and other risk factors for TIA/stroke must be addressed, and patients educated. If the patient's comorbidities are not treated, it is just a matter of time before they suffer another TIA or stroke.
Stroke is not a recent phenomenon, it is not uncommon, nor is it poorly researched. It does not lack for well-written clinical treatment guidelines, nor for easily accessible summaries of clinical guidelines. Yet, despite the availability of effective treatments and well-validated treatment protocols, patients are not receiving the care they need and deserve. The data and resources we need are available to us and meaningfully reduce the impact of one of the most devastating medical afflictions in our country. From medical societies to third-party payers to each individual physician, it is time to look up from our desks and understand that the situation can be changed. More can be done.
Author Affiliations: From the Department of Medical Management, Cigna-Great West Healthcare, Dallas, TX.
Funding Source: Financial support for this work was provided by Boehringer Ingelheim.
Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.
Address correspondence to: Allan Jay Kogan, MD, MSS, ABFP, FAAFP, CPE, 8350 N Central Expressway, Suite M1000, Dallas, TX 75206. E-mail: firstname.lastname@example.org.
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