Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study

Abstract

Objectives To determine the extent to which secondary drug prevention for patients with stroke in routine primary care varies by sex, age, and socioeconomic circumstances, and to quantify the effect of secondary drug prevention on one year mortality by sociodemographic group. Design Cohort study using individual patient data from the health improvement network primary care database. Setting England. Participants 12 830 patients aged 50 or more years from 113 general practices who had a stroke between 1995 and 2005 and who survived the first 30 days after the stroke. Main outcome measures Multivariable associations between odds of receiving secondary prevention after a stroke, and sex, age group, and socioeconomic circumstances; hazard ratios for all cause mortality from 31 days after the stroke and within the first year among patients receiving treatment and by social group; and probabilities of one year mortality for social factors of interest and treatment. Results Only 25.6% of men and 20.8% of women received secondary prevention. Receipt of secondary prevention did not vary by socioeconomic circumstances or by sex. Older patients were, however, substantially less likely to receive treatment. The adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.53 (95% confidence interval 0.41 to 0.69). This was because older people were less likely to receive lipid lowering drugs-for example, the adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.44 (95% confidence interval 0.33 to 0.59). Secondary prevention was associated with a 50% reduction in mortality risk (adjusted hazard ratio 0.50, 95% confidence interval 0.42 to 59). On average, mortality within the first year was 5.7% for patients receiving treatment compared with 11.1% for patients not receiving treatment. There was little evidence that the effect of treatment differed between the social groups examined. Conclusion Under-treatment among older people with stroke in routine primary care cannot be justified given the lack of evidence on variations in effectiveness of treatment by age. INTRODUCTIONThe contribution of medical care to population health has been a topic of scientific debate for years. McKeown's work sparked controversy, but there is agreement with his claim that clinical interventions played little part in the decline in mortality before the mid-20th century.1 Major advances in medical technology during the 20th century stimulated a re-examination of the role of health care in population health. International studies have focused on coronary heart disease. These suggest that 50-75% of the reductions in deaths from cardiac causes can be attributed to improvements in the major risk factors at population level, particularly smoking but also cholesterol levels and blood pressure, 2-5 whereas the remaining 25-50% can be attributed to medical intervention. Among patients with established coronary heart disease, nearly 78% of prevented or postponed deaths are attributable to medical or surgical interv...

Use of Secondary Medical Prophylaxis and Clinical Outcome Among Patients With Ischemic Stroke

“…One recent study, which investigated the effectiveness of secondary drug prevention as a pooled analysis of antihypertensives, lipid-lowering drugs and antithrombotics, found this treatment to be associated with a significant reduction in mortality risk. 7 This is in accordance with our findings in which use of antithrombotics, antihypertensives, and statins was associated with an apparently independently reduced risk of all-cause mortality. The effectiveness of antiplatelet therapy in secondary prophylaxis after stroke has also been investigated in 3 recent Chinese publications.…”

“…1,2 Although RCT findings on efficacy cannot automatically be expected to represent effectiveness in clinical settings, few studies have examined the effectiveness of secondary stroke prevention. [3][4][5][6][7][8] Current stroke guidelines recommend that lifelong medical prophylaxis including antithrombotic, antihypertensive, and lipid-lowering therapy be considered for all patients with ischemic stroke regardless of age and sex. 1,2 However, a number of studies have demonstrated an insufficient implementation of secondary prophylaxis in patients with stroke.…”

The UK National Health Service

“…Age inequalities in the treatment of cardiovascular disease are common in both the United States and Europe [34][35][36][37] and may in part relate to increasing comorbidity and contraindications, which we were unable to assess in this data set. Nevertheless, previous studies have demonstrated age inequalities that are independent of eligibility, 34,36 and unless this reflects explicit informed patient choice, ageism remains a concern.…”

Cluster Randomized Controlled Trial of a Patient and General Practitioner Intervention to Improve the Management of Multiple Risk Factors After Stroke

“…6 -8 Currently there are both discouraging and encouraging reports about aspects of secondary prevention management in the United Kingdom. Studying general practice records between 1995 and 2005, Raine et al 9 showed that only 25.6% of men and 20.8% of women received secondary prevention. A study of Quality and Outcomes Framework data in England between 2005 and 2007 showed that 82.3% of adults had an up-to-date blood pressure recording in 2005 and this increased to 88.3% in 2007.…”