The nGMS contract should provide a springboard for a holistic approach to the management of patients who have suffered a stroke or TIA, says Dr Alan Begg
Stroke is the second most common cause of death in the UK, and the resulting chronic disability in those who survive a stroke is a major burden for society. As the proportion of older people in the population rises the number of new strokes is projected to increase – one in four men and one in five women who survive to age 85 can expect to suffer a stroke.1
It is therefore appropriate that evidence-based strategies for the secondary prevention of stroke and transient ischaemic attack (TIA) should form an important component of the quality and outcomes framework (QOF) of the nGMS contract (Table 1, below, Box 1, below).
|Table 1: Clinical indicators for stroke and transient ischaemic attack|
|Clinical indicator||Points||Payment stages|
|Stroke 1||A register of stroke or TIA patients||4|
|Stroke 2||% new patients with presumptive stroke after 1/4/03 referred for CT or MRI scan for confirmation of diagnosis||2||25||80|
|Stroke 3||% patients with smoking status recorded in past 15 months. If never smoked, recorded at least once since diagnosis||3||25||90|
|Stroke 4||% smokers offered, or referred for, smoking cessation advice in past 15 months||2||25||70|
|Stroke 5||% with BP recorded in past 15 months||2||25||90|
|Stroke 6||% patients with last BP reading 150/90 mmHg or less measured in past 15 months||5||25||70|
|Stroke 7||% patients who have total cholesterol measured in past 15 months||2||25||90|
|Stroke 8||% patients whose last measured cholesterol is 5 mmol/l or less, measured in past 15 months||5||25||60|
|Stroke 9||% patients with non-haemorrhagic stroke or TIA on antithrombotic therapy||4||25||90|
|Stroke 10||% patients who have had flu immunisation in preceding 1 September - 31 March||2||25||85|
|Box 1: Stroke and TIA action
CT scan, brain
Refer for CT scan
Refer for NMR scan
Smoking cessation advice
Total cholesterol measurement
Is it a stroke?
Effective secondary prevention in patients who have had a stroke is dependent on the correct diagnosis of cerebral infarct or haemorrhage (Box 2, Box 3, below) as well as the exclusion of tumours and non-vascular lesions. It is impossible to differentiate an infarct from a haemorrhage by clinical examination, and computed tomographic (CT) scanning is the most common brain imaging used for this purpose.
|Box 2: Types of stroke|
|Primary cerebral haemorrhage||13%|
|Box 3: Stroke and TIA diagnostic
|Cerebral arterial occlusion||G64..|
|Transient cerebral ischaemia||G65zz|
A cerebral haemorrhage can be demonstrated as a hyperdense area on a CT scan as soon as clinical symptoms appear. As the haemorrhage is broken down this area becomes less dense until it is indistinguishable from an infarct.1 CT scanning is therefore useful only in the first 8 days.
With magnetic resonance imaging (MRI), the haemorrhage is visible for much longer. However, the procedure is contraindicated in patients with pacemakers and metal implants and many patients are unable to tolerate the enclosed imaging tunnel.
Confirming the diagnosis of a TIA is even more difficult. One study showed that 40% of patients referred with this diagnosis do not have it confirmed.2
On discharge from hospital, because of their ongoing physical and social needs, stroke patients are likely to have more contact with the medical and community services than most other patients. This enables practices to keep their registers up to date.
The information required can be fed into the practice database from the following sources:
- Discharge planning service
- Immediate discharge letter
- Stroke liaison service
- Community nurse caseload
- Care in the community service
- Family support workers.
Comprehensive stroke care
The clinical indicators concerned with ongoing management represent only some of the main measurable parameters for ongoing stroke care.
Stroke patients’ needs may be extensive and varied, and the annual review required by the QOF provides an opportunity for the clinician to assess what help can be provided.
Using the components outlined in Box 4 (below), practices can develop their own protocol and checklist based on local services. This will help the team member carrying out the review to ensure that all the patient’s needs are met and that he or she has access to other agencies.
|Box 4: Components of long-term structured follow-up care and support for stroke patients in primary care|
Management of stroke patients involves many different agencies and their work can help practices to achieve a high score in the clinical indicators.
Stroke family support workers, who may be nurses or social workers, provide education, advice and support to patients and their carers. The evidence indicates that carers may derive more benefit from this than patients,3 but the practice can enlist the support worker’s help when there are concerns over adherence to a treatment regimen.
Developing a stroke liaison team should help a practice to manage its stroke patients more appropriately. Although their benefits have yet to be quantified, these teams have a variety of possible roles in arranging patient care, which include:
- Ensuring seamless transition into the community
- Providing care and support to patients and carers
- Supporting the primary care team.
Reducing cardiovascular risk
Blood pressure (Stroke 6)
The benefits of lowering blood pressure in patients with a history of haemorrhagic and ischaemic stroke or TIA are clear from the PROGRESS study.4 The benefits of blood pressure lowering on stroke recurrence and major cardiovascular events were seen in all patients, including those with blood pressure levels not normally considered to be hypertensive.
The implication is that any patient who survives a stroke should undergo therapy to reduce blood pressure, even if it is not significantly raised. The audit standard target of 150/90 mmHg may be insufficient to maximise patient benefits and achieving a lower target should be the aim.
Cholesterol lowering – ischaemic stroke (Stroke 7 and 8)
The Heart Protection Study (HPS)5 included 3280 people with a previous non-disabling ischaemic stroke, TIA or carotid procedure prior to randomisation.
There was a highly significant 20% reduction in the rate of any major vascular event in those taking simvastatin, confirming the benefits of statin treatment in these patients.
However, with simvastatin there was no apparent reduction in the rate of stroke during the scheduled treatment period, although there was a non-significant trend towards fewer ischaemic strokes.
Anti-platelet therapy (Stroke 9)
Prolonged anti-platelet therapy confers significant benefits in patients who have suffered an ischaemic stroke or TIA.6 It can bring about a significant reduction in non-fatal stroke and myocardial infarction, and also reduce the risk of death in these patients.
There is an excess of bleeding, including extracranial bleeds associated with the use of aspirin, but the benefits clearly exceed the excess risk. For those unable to tolerate aspirin, clopidogrel as a single therapy is a suitable alternative,7 but the combination of aspirin and clopidogrel confers no benefit in stroke patients unless they also have acute coronary syndrome.
However, the combination of aspirin 25 mg twice daily and modifiedrelease dipyridamole 200 mg twice daily has been shown to have significant benefits in those who had experienced a TIA or a completed ischaemic stroke.8
Dipyridamole should be used with caution in patients with worsening angina, aortic stenosis, recent myocardial infarction and heart failure.9
Targeting those with most to gain
Flu immunisation (Stroke 10)
One of the strengths of the QOF is that it encourages GPs to target patients at highest risk who have the most to gain from preventive measures.
This is clearly illustrated by the increased uptake of flu immunisation in our practice. In previous years we have been encouraged to adopt a population-based approach to the over-65 at-risk group, and this has tended to favour mobile patients who have been able to attend an immunisation session. Last year, only 72% of stroke patients received flu immunisation, below the level for the over-65 group as a whole. However, this year with appropriate targeting, the figure has risen to 94%.
The codes for exception reporting should be used in line with the evidence and the contract guidance (Box 5, below).
|Box 5: Stroke and TIA exception codes|
CT scan brain declined
MRI scan declined
Maximum tolerated BP treatment
Angiotensin-converting enzyme inhibitor:
Angiotensin II receptor antagonist:
Maximum tolerated lipid-lowering treatment
Causes adverse effects
Salicylates - adverse reaction
It may be inappropriate to review all parameters in some stroke patients because of their extreme frailty. This can be decided either at the patient’s annual review date or towards the end of each accounting year.
Cholesterol lowering – haemorrhagic stroke
Concerns that cholesterol lowering might increase the risk of cerebral haemorrhage have previously been expressed.10 In the Heart Protection Study, the same numbers of patients in the control and the statin treatment groups suffered a cerebral haemorrhage, providing some evidence that this may not be the case.
The contract guidance indicates that clinicians should consider the competing risks in patients who have a proven haemorrhagic stroke and use exception reporting as appropriate.
Exception reporting on the basis of age would be acceptable only if there were clear evidence of lack of benefit from an intervention. The patients included in the PROGRESS,4 Heart Protection Study 11 and CAPRIE 7 studies were aged up to 75, 80 and 76 years respectively, and the mean age in the ESPS 2 study 8 was 70 years.
The decision as to how aggressively to manage risk factors should therefore be considered on an individual basis, taking into account:
- The patient’s wishes
- Level of disability
- Cognitive function
- Biological age
- Presence of co-morbidities.
Through the QOF there is now a national programme for quality care in general practice. Reporting databases from practice IT systems and the Quality Management and Analysis System (QMAS) allow practices to carry out ongoing audit of their performance and to measure the improvements made (Figure 1, below).
|Figure 1: Townhead practice nGMS contract stroke indicators|
National and regional prevalence rates are now available, enabling comparisons to be made to help in targeting local resources and providing services.
The QOF review group is currently reviewing the latest evidence so as to incorporate it into the revised version which will come into effect in April 2006. As far as the stroke indicators are concerned, this review needs to clarify the evidence base in respect of:
- Secondary prevention after subarachnoid haemorrhage
- The need for statin use
- Cholesterol lowering in different diagnostic categories
- Target blood pressures
- When to use combination antiplatelet therapy.
Addressing these inconsistencies will allow us to have a significant impact on the health of stroke patients across the UK.
- Wardlaw JM,Keir SL, Seymour J et al.What is the best imaging strategy for acute stroke? Health Technology Assessment 2004; 8(1).
- Martin PJ,Young G,Enevoldson TP,Humphrey PR. Overdiagnosis of TIA and minor stroke: experience at a regional neurovascular clinic.Q J Med 1997; 90: 759-63.
- Langhorne P, Legg L. Evidence behind stroke rehabilitation. Neurol Neurosurg Psychiatry 2003; 74(Suppl 4): iv18-iv21.
- Progress Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033-41.
- Collins R, Armitage J, Parish S et al; Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004; 363: 757-67.
- Anti-thrombotic Trialists’ Collaboration. Collective meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high-risk patients. Br Med J 2002; 324: 71-86.
- A randomised,blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348: 1329-39.
- Diener HC, Cunha L, Forbes C et al. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143(1-2): 1-13.
- British National Formulary 2005; 49: 127. http://www.bnf.org/bnf/
- Jacobs D, Blackburn H, Higgins M et al. Report of the Conference on Low Blood Cholesterol: Mortality Associations. Circulation 1992; 86: 1046-60.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7-22.