Primary care physician-reported secondary and tertiary stroke prevention practices: A comparison between the United States and the United Kingdom
Goldstein LB., Farmer A., Matchar DB.
Background and Purpose: Stroke is a major healthcare problem in both the United States (US) and the United Kingdom (UK). Little comparative data are available concerning how generalist physicians in the two countries approach the management of patients at high risk of stroke. Methods: Contemporaneous surveys of random samples of primary care physician-reported stroke prevention practices were performed in the US and UK from 1993 to 1994. The US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke included 254 noninternist primary care physicians. The UK Survey of the Care of Patients With Stroke in General Practice obtained responses from 661 general practitioners. The two surveys used many of the same questions, allowing for direct comparisons of reported stroke prevention practices between American and British physicians. Results: More than 80% of American physicians reported a variety of services (24-hour electrocardiography, echocardiography, brain CT scan, brain MR scan, carotid ultrasonography, cerebral angiography) as readily available. These same services were readily available to less than 10% of physicians in the UK (P<.001 for each comparison). Although physicians in the UK reported prescribing lower doses of aspirin for stroke prevention than physicians in the US, the proportions of physicians using aspirin were not different. In contrast, almost 70% of physicians in the US responded that they always or often anticoagulate patients with nonvalvular atrial fibrillation compared with 7% of British physicians (P<.001). Whereas 70% of American versus 14% of British physicians reported obtaining carotid ultrasound studies in patients with asymptomatic bruits (P<.001), physicians in the UK more commonly reported referring this type of patient to neurologists (46% versus 21%, P<.001). For patients with recent carotid-distribution transient ischemic attack or minor stroke, physicians in the US more commonly reported referral to neurologists (55% versus 45%, P=.022), referral to surgeons (39% versus 19%, P<.001), the performance of carotid ultrasonography (80% versus 11%, P<.001), echocardiography (45% versus 5%, P<.001), 24-hour electrocardiography (49% versus 4%, P<.001), brain CT scan (72% versus 3%, P<.001), and the prescription of anticoagulants (53% versus 4%, P<.001). Conclusions: These data show significant differences in stroke prevention practices as reported by primary care physicians practicing in the US and UK. Some of these differences may be related to the relative availability of specific services in the two countries, potentially leading to overutilization in the US and underutilization in the UK in certain circumstances.