In the United States, we see nearly 800,000 strokes each year—amounting to a new or recurrent stroke occuring every 40 seconds. Fortunately, with notable improvements in care, many more people are surviving strokes than in the past. Stroke survival, however, brings its own set of demands on the health care delivery system, with many patients needing extensive support from physicians, therapists, and family members.
Current efforts around developing certified Comprehensive Stroke Centers (written about earlier this week on The Pipeline) are focused on enhancing acute and post-acute care for stroke, but with much of the health care dialogue centered on population care management, a focus on stroke prevention may become a more realistic goal for the delivery system.
An article published last week in BMJ Open suggests that the possibility of reducing the incidence of stroke can be realized through improved management of known risk factors. While the study arrives at its conclusion in a weak manner, the story is compelling.
Researchers from the United Kingdom analyzed epidemiological data from the country's General Practice Research Database (GPRD) to find trends in stroke from 1999 to 2008. The initial findings are impressive: Overall stroke incidence fell by 30%, among the highest risk group (those over 80 years of age) stroke incidence fell by 42%, and overall mortality after stroke decreased from 21% in 1999 to 12% in 2008. For an aging population, such figures are startling. The authors surmise that more aggressive management of cardiovascular risk factors "is likely to be a major contributor" to the reduced incidence observed, citing the Quality and Outcomes Framework, an incentive scheme for general practioners in the UK that targets improvements in care for, among many other things, cardiovascular disease and hypertension.
Over the time period investigated, the authors show how the use of antihypertensive, antiplatelet, anticoagulant, and lipid regulating drugs increased prior to first stroke and in the year following first stroke. The overall rate of pharmaceutical therapies (i.e., those prescribed to non-stroke patients) are not included in the article—though the authors site a couple of other studies that support their claim. This lack of evidence undermines the crux of the study. The authors conclude that a dramatic reduction in stroke incidence can be partially attributed to an increase in pharmaceutical therapies for cardiovascular disease, yet they choose to support that argument with evidence of the use of drugs among patients that did suffer strokes. There is nothing in the study that explicitly estimates high-risk patients that may have avoided a stroke because their cardiovascular disease was being managed through appropriate drugs. That line of argument would have been helpful, but such as it is, the article leaves it in the reader's hands to attempt to tie it together.
Regardless of the weak evidence presented, the story here is compelling. We're told that the use of medication to manage cardiovascular risk factors has increased across the population of the UK, and corresponding with that rise has been a noticeable drop in the incidence of stroke. The advantages of managing high cholesterol and hypertension are well known and extend beyond the reduced risk of stroke. Under new payment and delivery models in this country, the advantages of reducing stroke incidence in a patient population could become more financially beneficial, especially under shared savings, in which the cost of delivering care to a group of patients could be noticeabley reduced should the rate of strokes be reduced. More agressive primary care management of cardiovascular disease will be one key strategy in seeing those reductions.