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Stroke Prevention Practices Differ Significantly Between United States and United Kingdom

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ANAHEIM, CA. -- Patients at high risk for stroke are much more likely to be referred to advanced diagnostic procedures and/or treated aggressively with anticoagulant drugs in America than in the United Kingdom, according to a survey of generalist primary care physicians in both countries.

In the British system, which is government supported, primary care physicians have long acted as a "gatekeeper" to specialist care, referring patients to specialists for advanced diagnostic procedures and therapies. In the United States, more and more primary care physicians are assuming the role of gatekeeper in managed care programs.

Dr. Larry Goldstein, Duke neurologist and faculty member of Duke's Center for Health Policy Research and Education (CHPRE), presented the results of the survey Saturday at the American Heart Association's 22nd international Joint Conference on Stroke and Cerebral Circulation.

"The U.S. and the U.K. are two industrial societies with similar demographics and medical traditions," said Goldstein. "The health care delivery systems in the U.K. and Western Europe are driven by the primary care model. What we learn from these comparisons could have implications for how physicians in both countries treat their patients as well as provide the basis for future studies."

Goldstein and his collaborator, Dr. Andrew Farmer of Oxford University, conducted detailed surveys of physician perceptions and self-reported practices and found that by an overwhelming majority American physicians felt they had greater access to a wide range of diagnostic procedures.

"More than 85 percent of the American physicians reported that such tests as 24-hour electrocardiograms (ECG), echocardiography, brain CT scans, brain MRI scans, carotid ultrasonography and cerebral angiography were readily available," Goldstein said. "However, fewer than 10 percent of the U.K. physicians reported that these services were readily available."

British primary care physicians perceive that many of these tests are relatively unavailable, which affects how their patients are treated, Goldstein said. Whether these tests are in reality unavailable is not known, Goldstein said. But he said perceptions often guide decision-making.

In the United States, the survey questions were developed as a part of the National Physician Survey of Secondary and Tertiary Stroke Prevention Practices, which was supported by the U.S. Agency for Health Care Policy Research. The U.K. Survey of the Care of Patients with Stroke in General Practice was supported by the Anglia and Oxford Regional Health Authority Health Promotion Fund.

The study compared practices of 254 non-internist primary care physicians in the U.S. to 661 general practitioners in the U.K. Non-internist primary care physicians were chosen because their training most closely approximates their U.K. counterparts.

The surveys, which were taken in 1993 and 1994, included many of the same questions, which allowed for a direct comparison of physician practices in the two countries, Goldstein said.

Another striking difference was the reported use of the anticoagulant warfarin for patients with atrial fibrillation, an irregular heart rhythm that can create stroke-causing blood clots.

"Approximately 75 percent of the American physicians reported always or often prescribing anticoagulants for this type of patient; the same percentage of British physicians reported seldom or never using anticoagulants," Goldstein said. "We can't explain these differences; however, they could be potentially explained by the fact that American physicians may be more readily able to obtain the monitoring necessary with the use of warfarin."

Other findings include:

The British physicians prescribed lower doses of aspirin than U.S. physicians -- less than one adult aspirin a day. Whereas 70 percent of American vs. 14 percent of British physicians reported obtaining carotid ultrasounds for patients of asymptomatic bruits (sounds in the carotid artery in the neck that may signal a stroke), British physicians more commonly (46 percent vs. 21 percent) referred these patients to neurologists or hospital physicians. Goldstein attributed the difference to the U.K. physician perception that ultrasonography was unavailable.

While the incidence of stroke is roughly equal in both countries, and the mortality rates are slightly higher in the U.K., Goldstein said there are no reported comparable outcomes data about patients with different risk factors for stroke. A prospective study would need to be conducted to determine whether the dramatic differences in practices between the two countries affect outcomes, Goldstein said.

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