Editorials

Decreasing the Morbidity, Mortality, and Cost of Stroke Through Awareness and Prevention

See article on page 2379.

MARGARET GRADISON, M.D.
Duke University Medical Center
Durham, North Carolina

Stroke is a significant medical problem that affects more than 700,000 Americans annually.¹ In the United States, it is the third leading cause of death, the major cause of disability, and the primary reason for nursing home admissions.^1,2 Because of the aging of the U.S. population and the increasing incidence of chronic illnesses, the rate of stroke and its associated costs will continue to escalate. Unfortunately, public awareness of the warning signs of stroke and its early treatment remain limited.^3,4

In this issue of American Family Physician, Ezekowitz and associates⁵ review strategies that have been shown to be effective in stroke prevention. It is clear that preventive measures and early interventions can reduce the morbidity, mortality, and cost of stroke. Thus, physicians need to recognize which patients are at risk for stroke and design systematic approaches to these patients.⁶ In addition, medical education needs to focus on stroke prevention and the care of patients who experience a stroke.⁷

Primary prevention of stroke includes the treatment of hypertension and hyperlipidemia, the use of angiotensin-converting enzyme inhibitors and glucose control in patients with diabetes, the use of warfarin (Coumadin) in patients with atrial fibrillation, and smoking cessation. Weight reduction in obese patients and increased physical activity also should be encouraged. Low-dose aspirin has not been shown to be effective in preventing a first stroke and, in fact, can increase the risk of hemorrhagic stroke.⁸ Secondary prevention of stroke may include the use of antiplatelet agents, aspirin, warfarin, statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors), and carotid surgery. Treatment of chronic diseases such as hypertension and diabetes should follow accepted evidence-based guidelines.^9,10

The media (particularly television) and community-based education in settings such as schools and churches can help to increase public awareness of the warning signs and early treatment of stroke.^11,12 In addition, medical office personnel must be able to provide proper advice when a patient or family member calls to report signs suggestive of stroke. If there is a possibility that a patient could be having a stroke, "9-1-1" should be called immediately. Delay in treatment because the signs of stroke were not recognized results in a poorer outcome.¹³ The patient with a possible stroke must be a top priority and should be transported to an appropriate facility by an emergency medical service, rather than by private car.¹⁴

Hospital emergency departments should develop triage systems to care for patients who have signs consistent with stroke.¹⁴ Triage should be similar to that in patients with chest pain who may have cardiac disease. Fever, blood glucose levels, and blood pressure must be managed, and consideration should be given to immediate administration of aspirin.

Good evidence shows that patients with an ischemic stroke who meet specific criteria benefit from the administration of tissue-type plasminogen activator (tPA) if the tPA is given within three hours of the onset of symptoms.¹⁴ Strict adherence to the protocol for tPA administration increases efficacy and safety.¹⁵ Hospitals that provide emergency stroke care should have a protocol in place for tPA administration or be prepared to transfer patients to a better equipped facility.

Not all hospitals have 24-hour radiology, laboratory, and neurosurgery services. Hence, the staff and administrators of each hospital must determine the level of stroke care their institution can provide. The community then must determine the best use of local resources to accommodate its residents.¹⁶

As family physicians, we can do much to increase awareness of stroke, promote its prevention, and provide education about its treatment. We can implement office systems to enhance prevention, and we can establish awareness campaigns in our offices, in emergency responders, in hospitals, and within our communities. By helping to create these systems, family physicians can work with their communities to decrease the morbidity, mortality, and cost of this devastating illness.

Margaret Gradison, M.D., is associate clinical professor and chief of the Division of Family Medicine, Department of Community and Family Medicine, Duke University Medical Center, Durham, N.C.

Address correspondence to Margaret Gradison, M.D., Duke University Medical Center, Box 3776, Durham, NC 27710 (e-mail: gradi001@mc.duke.edu). Reprints are not available from the author.

REFERENCES

1. Minino AM, Arias E, Kochanek KD, Murphy SI, Smith BL. Deaths: final data for 2000. Natl Vital Stat Rep 2002;50(15):1-119.
2. American Heart Association. Heart disease and stroke statistics--2003 update. Dallas: American Heart Association, 2002. Accessed October 10, 2003, at: http://www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf.
3. Goldstein LB, Gradison M. Stroke-related knowledge among patients with access to medical care in the stroke belt. J Stroke Cerebrovasc Dis 1999;8: 349-52.
4. Pancioli AM, Broderick J, Kothari R, Brott T, Tuchfarber A, Miller R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279:1288-92.
5. Ezekowitz JA, Straus SE, Majumdar SR, McAlister FA. Stroke: strategies for primary prevention. Am Fam Physician 2003;68:2379-86,2389-90.
6. Solberg LI. The KISS principle in family practice: keep it simple and systematic. Fam Pract Manag 2003;10:63-6.
7. Alberts MJ. Undergraduate and postgraduate medical education for cerebrovascular disease. Stroke 1995;26:1849-51.
8. Hart RG, Halperin JL, McBride R, Benavente O, Man-Son-Hing M, Kronmal RA. Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses. Arch Neurol 2000;57:326-32.
9. Straus SE, Majumdar SR, McAlister FA. New evidence for stroke prevention: scientific review. JAMA 2002;288:1388-95.
10. Gorelick PB, Sacco RL, Smith DB, Alberts M, Mustone-Alexander L, Rader D, et al. Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA 1999;281:1112-20.
11. Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T. Community-based education improves stroke knowledge. Cerebrovasc Dis 2001; 11:34-43.
12. Alberts MJ, Perry A, Dawson DV, Bertels C. Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke 1992;23:352-6.
13. Brice JH, Griswell JK, Delbridge TR, Key CB. Stroke: from recognition by the public to management by emergency medical services. Prehosp Emerg Care 2002;6:99-106.
14. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283:3102-9.
15. Albers GW, Bates VE, Clark WM, Bell P, Verro P, Hamilton SA. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000;283:1145-50.
16. Improving the chain of recovery for acute stroke in your community. Task force reports (NIH publication no. 03-5348). Bethesda, Md.: National Institute of Neurological Disorders and Stroke (In press).

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Clinical Inquiries from the Family Practice Inquiries Network

See article on page 2437.

JOHN EPLING, M.D.
State University of New York-Upstate Medical University
Syracuse, New York

BERNARD EWIGMAN, M.D., M.S.P.H.
University of Chicago Medical Center
Chicago, Illinois

MARK H. EBELL, M.D., M.S.
Michigan State University College of Human Medicine
East Lansing, Michigan

Family physicians have many questions about appropriate diagnoses and treatments of their patients. These questions sometimes go unanswered because some of us do not have ready access to efficient resources to find answers, because the answers we find are not relevant to our practice, or because the urgencies of the day outweigh the need to search for an answer.¹ Even when these questions are answered, the resources used may not reflect current knowledge or best practice. To help resolve this problem, American Family Physician begins a new department entitled, "Clinical Inquiries from the Family Practice Inquiries Network." This department joins other recently added departments and features containing content based on the most current and highest quality evidence.

The Family Practice Inquiries Network (FPIN) is a national, not-for-profit consortium of academic family medicine departments, family medicine residency programs, practicing family physicians, medical librarians, and other professionals. FPIN is dedicated to making information available to physicians at the point of care, and to generating new research-based evidence relevant to primary care. FPIN offers an online database of clinical answers that is accessible to paid subscribers (http://www.fpin.org).

Practicing physicians, like our readers, can submit questions about their patients to FPIN. The questions to be answered are selected by groups of practicing family physicians who vote through an online ballot. Questions are assigned to authors who search a set of selected, high-quality databases (see accompanying table) and answer the questions using the best evidence found in those databases. The evidence for each answer is summarized, appraised, and graded. The answer is put into a standard, easy-to-use format for quick reading. Each answer is peer reviewed.

Required Databases for Answering Clinical Inquiries Database, Web address Agency for Healthcare Research and Quality, Clinical Guidelines and Evidence Reports, http://www.ahrq.gov/clinic/ American College of Physicians Journal Club,* http://www.acpjc.org Bandolier, http://www.jr2.ox.ac.uk/Bandolier Clinical Evidence from BMJ Publishing,* http://www.clinicalevidence.com Cochrane Database of Systematic Reviews, http://www.cochrane.org Database of Abstracts of Reviews of Effectiveness (DARE), http://agatha.york.ac.uk/darehp.htm Evidence-Based Medicine,* http://www.evidence-basedmedicine.com InfoRetriever,* http://www.infopoems.com Institute for Clinical Systems Improvement (ICSI), http://www.icsi.org National Guideline Clearinghouse, http://www.guidelines.gov U.S. Preventive Services Task Force (USPSTF), http://www.ahrq.gov/clinic/uspstfix.htm *--Subscription required to access database.

If the selected databases do not provide sufficient information to answer a question, the question is referred to one of FPIN's medical librarians, who conducts a systematic bibliographic search of MEDLINE and other sources to identify resources that the author can use to prepare an answer.

FPIN is working to create an online database that can provide answers to 80 percent of common questions within 60 seconds. The database of answers is available to FPIN subscribers and will be updated as necessary. The "Clinical Inquiries" articles in AFP will represent some of the most common questions. As with most content appearing in AFP, the "Clinical Inquiries" department is available online at http://www.aafp.org/afp.

Readers of AFP who have questions about the "Clinical Inquiries" department can contact John Epling, M.D., associate editor for FPIN, by e-mail (eplingj@upstate.edu) or through the FPIN's Web site (http://www.fpin.org/Inquiries/Clinical2/Default.aspx).

FPIN would be happy to involve you in the generation of questions and the question selection process. If you would like to submit a question to be answered or if you want to vote on submitted questions, you are welcome to send an e-mail to questions@fpin.org. For membership information, send an e-mail to membership@fpin.org

AFP and FPIN hope this new department will assist you in providing high-quality care for your patients.

John Epling, M.D., is associate editor for the Family Practice Inquiries Network, and an assistant professor in the Department of Family Medicine at State University of New York-Upstate Medical University, Syracuse, N.Y.

Bernard Ewigman, M.D., M.S.P.H., is editor-in-chief for the Family Practice Inquiries Network and chairman of the Department of Family Medicine at the University of Chicago Medical Center, Chicago.

Mark H. Ebell, M.D., M.S., has a private practice in Athens, Ga., and is associate professor in the Department of Family Practice at Michigan State University College of Human Medicine, East Lansing. He is also deputy editor for evidence-based medicine for American Family Physician.

Address correspondence to John Epling, M.D., Department of Family Medicine, SUNY-Upstate Medical University, 475 Irving Ave., Suite 200, Syracuse, NY 13210 (e-mail: eplingj@upstate.edu).

REFERENCE

1. Ely JW, Osheroff JA, Ebell MH, Chambliss ML, Vinson DC, Stevermer JJ, Pifer EA. Obstacles to answering doctors' questions about patient care with evidence: qualitative study. BMJ 2002; 324:710-3.

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STEPS Drug Updates

See article on page 2429.

ALLEN F. SHAUGHNESSY, PHARM.D.
Pinnacle Health System
Harrisburg, Pennsylvania

Sorting through the myriad of claims to figure out if you should add a new drug to your arsenal is not that difficult or time consuming, providing you take the right STEPS. STEPS, one of the newest additions to American Family Physician, offers an easy way to remember the four attributes to consider when weighing the purported advantages of one drug over another: Safety, Tolerability, Effectiveness, Price, and Simplicity.

Safety. The safety profile of a drug applies to the risk of long-term or serious side effects caused by the drug. An older, more established drug may have more risks identified with it than a new drug that has been studied only in a limited number of patients. However, unlike the old saying, what we don't know really can hurt us. When safety is an issue, "watchful waiting" for the first year or so after a new drug is released will allow you to benefit from the experience of others without exposing your patients to unnecessary risk.

Tolerability. Tolerability focuses on the less serious but bothersome side effects of a drug such as drowsiness or insomnia. Determining relative tolerability of two drugs can be difficult if you try to sort through long lists of reported side effects. Pooled dropout rates, the percentage of patients who stopped taking a particular drug during clinical trials, is a better indicator of the relative tolerability of two drugs. For example, headache or nausea may occur less often with a new drug, although, overall, patients are no more likely to stop taking the new drug because of side effects than the older drug.

Effectiveness. The best effectiveness data will compare the new drug against the drug in current use. However, this type of direct comparison may not be available when a drug is first marketed. If it is, make sure it shows similar effectiveness as measured in terms of results that patients care about (and not the relative effects on cellular receptors, their in vitro activity, or effects on various blood levels).

Price. Cost can be a complex subject. Does the price, if higher than the agent you currently use, justify the added benefits of the new drug? Included in your price considerations also should be the cost of additional monitoring that might be necessary with the new agent.

Simplicity. Oftentimes, a new drug will offer greater simplicity. It can be taken less often, does not require special handling (e.g., refrigeration), or does not interact with other commonly used drugs.

The categories making up STEPS are not always equal; sometimes effectiveness will be more important than the other characteristics; other times safety or tolerability will be paramount.

Sorting the information available into the five STEPS categories helps determine what is known about a new drug, what is not known, what information is superfluous, and how it all adds up.

Allen F. Shaughnessy, Pharm.D., is director of medical education at Pinnacle Health System, Harrisburg, Pa. He is also the series coordinator of STEPS in American Family Physician.

Address correspondence to Allen F. Shaughnessy, Pharm.D., Pinnacle Health System, P.O. Box 8700, Harrisburg, PA 17105. Reprints are not available from the author.

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The Growing Mandate for Clinical Preventive Medicine

S. EDWARDS DISMUKE, M.D., M.S.P.H.
University of Kansas School of Medicine-Wichita
Wichita, Kansas

The potential to save lives and improve the quality of life for millions of Americans through clinical preventive medicine is tremendous. In their classic paper, McGinnis and Foege¹ linked one half of the mortality in the United States from the 10 leading causes of death to lifestyle-related behaviors.

One of the key strategies of the U.S. Department of Health and Human Services to improve the health of Americans is to focus on improving five of the lifestyle factors identified. They are tobacco use, overweight/obesity, lack of physical activity, substance abuse, and irresponsible sexual behavior. With their broad responsibilities for people across the entire lifespan, family physicians are ideally poised to lead the national effort in promoting clinical preventive medicine.

According to the Guide to Clinical Preventive Services,² clinical preventive medicine interventions can be divided into the areas of screening, counseling, immunizations, and chemoprophylaxis. To assimilate the large body of evidence about prevention, the Partnership for Prevention and other groups analyzed the 283 clinical interventions discussed in that guide based on the burden of disease prevented and the cost-effectiveness of the interventions.³ The highest ranked services with the lowest delivery rates (50 percent, nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairment, offering adolescents an antitobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease.

Probably the best tools for learning and implementing clinical preventive medicine are in A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach⁴ and the Guide to Clinical Preventive Services, Third Edition: Periodic Updates.⁵ These user-friendly packages of material (some of which have been published in this journal) come from the third U.S. Preventive Services Task Force (USPSTF); they have been organized by the Agency for Healthcare Research and Quality and are released incrementally. The reports also can be accessed easily online at http:// www.ahrq.gov/clinic/uspstFix.htm.

The USPSTF clearly states the evidence on which their recommendations for intervention are based. They grade their recommendations from "A" to "D" based on the strength of the supporting evidence. When the evidence is insufficient to recommend for or against an intervention or service, the grade of "I" is given.

Many medical specialty societies and disease-oriented organizations (e.g., the American Heart Association and the American Cancer Society) have developed their own recommendations for screening and prevention. Unfortunately, the various recommendations sometimes are in conflict. Family physicians and other physicians frequently are asked to use clinical judgment in the context of the physician-patient relationship to sort through conflicting recommendations. For example, the USPSTF has given a grade "I" recommendation for screening for prostate cancer with prostate-specific antigen (PSA) testing or digital rectal examination.⁶ At the same time, other organizations recommend PSA screening,^7,8 and some 27 states have passed laws requiring that insurance cover such screening.⁹

In these cases, physicians can inform or educate their patients in a "shared decision-making process." Even though the evidence is far from conclusive for this intervention, many patients still may wish to have the testing done.

The practicalities of organizing the physician's staff and practice to systematically implement clinical preventive services are discussed in A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach.⁴ In this guide, physicians are shown how staff can implement the program. Patient flow sheets that can be added to a patient's medical record help tremendously. In my own practice, I have used computerized histories and health-risk appraisals. I have been able to use the printouts for patient education and to start or complete a prevention flow sheet.

A particular challenge for physicians is to redesign practice systems to more cost-effectively carry out clinical preventive medicine. For instance, having special times, personnel, and routines to help groups of patients address issues of diet and weight loss are probably more cost-effective than dealing with each patient, one-on-one, at every visit.

Another major issue is trying to reach all potentially affected patients in a practice or community. Although most people consult their primary care physician every year, we do not have adequate systems to address prevention during every visit with every patient. In addition, many patients do not consult physicians frequently or are not compliant with medical recommendations. The growing evidence that some preventive interventions, such as those for diabetes management, can save insurance companies money is generating incentives to seek out all patients who can potentially benefit from the interventions.¹⁰

Time and reimbursement for prevention remain major issues. The good news is that delivery of clinical preventive services such as immunizations, mammograms, and cholesterol screening has risen steadily during the past two decades. Roughly 90 percent of employers now include well-child visits, childhood immunizations, screening tests, and adult physical examinations among covered health benefits, compared with less than one half of employers in 1988.¹¹

The ideal situation would be for physicians and their local communities to work together to link personal/clinical preventive medicine, with community/population-based prevention. These interventions should be linked to state and local health policy. The Centers for Disease Control and Prevention is beginning to report the findings of the U.S. Community Preventive Services Task Force. The future looks promising for community-wide prevention.

S. Edwards Dismuke, M.D., M.S.P.H., is Dean of the University of Kansas School of Medicine-Wichita, where he is also professor of preventive medicine and public health.

Address correspondence to S. Edwards Dismuke, M.D., M.S.P.H., Dean, KU School of Medicine- Wichita, 1010 N. Kansas, Wichita, KS 67214.

REFERENCES

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.
2. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Alexandria, Virginia. International Medical Publishing, Inc. 1996.
3. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med 2001;21:1-9.
4. A step-by-step guide to delivering clinical preventive services: a systems approach. Accessed November 12, 2003, at: http://www.ahrq.gov/ppip/manual.
5. U.S. Preventive Services Task Force. Guide to delivering clinical preventive services, 3d ed: periodic updates. Accessed November 12, 2003, at: http:// www.preventiveservices.ahrq.gov.
6. U.S. Preventive Services Task Force. Screening for prostate cancer: recommendation and rationale. Ann Intern Med 2002;137:915-6.
7. Smith RA, von Eshenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early lung cancer detection. CA: Cancer J. Clin. 2001;51:007-38.
8. Mandelson MT, Wagner EH, Thompson RS. PSA Screening: a public health dilemma. Ann Rev Public Health 1995;16:283-306.
9. State Cancer Legislative Database Program (SCLD). National Cancer Institute. Accessed November 12, 2003, at: http://www.scld-nci.net.
10. Rubin RJ, Dietrich KA, Hawk AD. Clinical and economic impact of implementing a comprehensive diabetes management program in managed care.
    J Clin Endocrinal Metab. 1998;83:2635-42.
11. Woolf SH, Atkins D. The evolving role of prevention in health care: contributions of the U.S. Preventive Services Task Force. Am J Prev Med 2001;20(suppl3).

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