Scholte op Reimer Wilma J M, Dippel Diederik W J, Franke Cees L, van Oostenbrugge Robert J, de Jong Gosse, Hoeks Sanne, Simoons Maarten L
Erasmus Medical Center, Department of Cardiology, Rotterdam, The Netherlands.
Stroke. 2006 Jul;37(7):1844-9. doi: 10.1161/01.STR.0000226463.17988.a3. Epub 2006 May 25.
Limited data are available on management of outpatients with stroke or transient ischemic attack (TIA) and on clinicians' reasons for withholding procedures recommended by guidelines. We assessed to what extent guidelines are appropriately applied after ischemic stroke or TIA, in admitted patients as well as outpatients.
A survey was conducted in 11 centers in the Netherlands, which prospectively enrolled 579 admitted patients and 393 outpatients. Data were collected by trained research assistants. Duplicate assessment in 10% of patients showed good agreement with neurologists (median kappa=0.86). Treating neurologists were asked to provide arguments for withholding recommended procedures in eligible patients.
Recommended acute procedures were provided in the majority of admitted patients, but less often in outpatients: brain imaging (98% and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests (97% and 86%), aspirin within 48 hours (90% and 68% of eligible patients). Secondary preventive measures were not always taken in both eligible inpatients and eligible outpatients: carotid endarterectomy (provided in 31% and 30% of patients), antiplatelet agents (93% and 90%), oral anticoagulants (60% and 48%), antihypertensive agents (57% and 44%), and cholesterol-lowering therapy (71% and 52%). Reasons for withholding recommended procedures were plausible for almost all admitted patients, but were unclear in the majority of outpatients.
Compared with other national stroke surveys, we found high-quality acute care in admitted ischemic stroke patients, whereas secondary prevention was comparably poor. Although the majority of our centers have rapid-access TIA clinics, there is still substantial potential to improve quality of stroke care in outpatients.
关于中风或短暂性脑缺血发作（TIA）门诊患者的管理以及临床医生不采用指南推荐程序的原因，相关数据有限。我们评估了在缺血性中风或TIA后，住院患者和门诊患者对指南的适用程度。
在荷兰的11个中心进行了一项调查，前瞻性纳入了579例住院患者和393例门诊患者。数据由经过培训的研究助理收集。对10%的患者进行重复评估，结果显示与神经科医生的评估具有良好的一致性（中位数kappa=0.86）。要求负责治疗的神经科医生为符合条件的患者不采用推荐程序提供理由。
大多数住院患者接受了推荐的急性治疗程序，但门诊患者接受的较少：脑部成像（分别为98%和93%）、12导联心电图（96%和81%）、实验室检查（97%和86%）、48小时内服用阿司匹林（符合条件患者的90%和68%）。二级预防措施在符合条件的住院患者和门诊患者中并非总是得到实施：颈动脉内膜切除术（分别在31%和30%的患者中实施）、抗血小板药物（93%和90%）、口服抗凝剂（60%和48%）、抗高血压药物（57%和44%）以及降胆固醇治疗（71%和52%）。几乎所有住院患者不采用推荐程序的理由都合理，但大多数门诊患者的理由不明确。
与其他全国性中风调查相比，我们发现住院缺血性中风患者接受了高质量的急性治疗，而二级预防则相对较差。尽管我们的大多数中心都设有TIA快速诊疗门诊，但门诊中风护理质量仍有很大提升空间。
