US NATIONAL SURVEY OF PHYSICIAN PRACTICES FOR THE SECONDARY AND TERTIARY PREVENTION OF ISCHEMIC STROKE - DESIGN, SERVICE AVAILABILITY, AND COMMON PRACTICES

Background and Purpose Stroke is largely a preventable disease. Howeve r, there are little data available concerning the use of stroke preven tion diagnostic and treatment modalities by practicing physicians. The se data are critical for the rational allocation of resources and targ eting of educational efforts. The purposes of this national survey wer e to gather information about physicians' stroke prevention practice p atterns and their attitudes and beliefs regarding secondary and tertia ry stroke prevention strategies. Methods We conducted a national surve y of stroke prevention practices among a stratified random sample of 2 000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and th e use of diagnostic and preventive strategies for patients at elevated risk of stroke. Besults Sixty-seven percent (n=1006) of eligible phys icians completed the survey. Diagnostic studies considered readily ava ilable by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and M RI scans. MR angiography was perceived as being readily available by 6 8% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logis tic regression analyses showed that the availability of services varie d with physician specialty (noninternist primary care, internal medici ne, neurology, surgery), practice setting (nonmetropolitan versus smal l metropolitan or large metropolitan areas), and for carotid endartere ctomy, region of the country (South, Central, Northeast, and West). Th e odds of carotid endarterectomy being reported as readily available w ere approximately 2.5 to 3.5 times greater for physicians practicing i n the central, northeastern, and western regions compared with those p racticing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reporte d prescribing 325 mg of aspirin for stroke prevention, while 33% recom mend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulati on with international normalized ratios. and 78% reported monitoring a nticoagulated patients at least once a month. Fewer than 20% of physic ians reported knowing the perioperative carotid endarterectomy complic ation rates at the hospital where they perform the operation themselve s or refer patients to have the procedure done. Conclusions Although a ll routine and most specialized services for secondary and tertiary st roke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for m onitoring warfarin therapy has not yet become universal. Physician kno wledge of carotid endarterectomy complication rates is generally lacki ng. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the wa y in which services are provided.