Knowledge, Skills and Practices of Transient Ischemic Attack Intervention amongst General Practitioners in Karachi, Pakistan

The risk of stroke has increased by 100% in low and middle income countries over the last decade with the developing world accounting for 85.5% of all stroke deaths worldwide [1]. Socioeconomic transition in low and middle-income countries is likely to increase the burden of cerebro-vascular disease [2, 3]. Among individuals older than 35 years, the overall prevalence of stroke in Pakistan is 21.8%, while transient ischemic attack (TIA) alone was reported 9.7% [3]. About 240,000 and 70,000 TIAs are diagnosed every year in the United States [4, 5], and the United Kingdom respectively [5, 6]. Patients with TIA are at a higher risk of full stroke and previous studies have found that 4-20% will have a stroke within 90 days after a TIA, half of these within the first two days [4, 5]. General practitioner (GPs) plays a very significant role in the assessment and management of TIA in any society. In Pakistan, despite the lack of core GP training program, GPs are the backbone of the medical community. In contrast to the importance of GPs in the provision of medical care in Pakistan, there is no accountability, check and balance, or requirement for refresher courses. TIA patients may minimize the urgency of their symptoms when presenting to a GP and may pose a diagnostic dilemma. Delay in diagnosis and proper management lead to poor prognosis as there is increasing evidence that early assessment and management of TIA patients is vital to prevent subsequent stroke. The aim of this study was to determine the Pakistani GPs knowledge of TIA recognition, assessment, and management and to identify the problems they face.

We enrolled 228 GPs from the 19 towns of Karachi, Pakistan for a survey questionnaire consisting of five sections. The first section was used to collect demographic information such as graduate and post-graduate qualification (if any) and years in general practice. Section 2-5 were case vignette-based questions with three possible responses (yes, no, and do not know). Case vignettes were written by three authors, two consultants, and one general practitioner, based on the typical neurological cases seen in general practice. The case vignette in section 2 dealt with the stratification of TIA risk. Vignettes in section 3 and 4 sought knowledge about investigations, risk factors, and management of TIA in patients presenting to GPs. Vignette in section 5 was designed to assess the knowledge of the GP in referring a patient to a specialized centre. While designing questionnaire, we observed methods to improve response rates, including topic relevance, feedback provision, questionnaire length, assurance of confidentiality, incentives, and personal contact. The questionnaire was approved by the institutional ethical review committee. Two research assistants were trained on questionnaire administration. The questionnaire was piloted in a group of 20 GPs, to ensure appropriateness and understanding. Questionnaires were physically taken to the GPs by research assistants who administered the questionnaire. Data Analysis: Statistical analysis was performed using SPSS (IBM SPSS Statistics 20.0). Data were expressed in frequencies for questionnaire responses calculated for all variables. Cross tabulation was performed to determine if there was a relationship between subgroups. Chi-square tests were used for comparative analysis.

GP Characteristics: The survey achieved a 100% response rate. Approximately 50% of GPs were between 25 and 30 years in age and 61.4% GPs were for 0 to 10 years in clinical practice; 54% were male; 42.5% saw less than 5 TIA patients per month; 35.1% saw 5-15 TIA patients per month; 50% were practicing solo and 40% were in group practices. Nearly two third (77%) of GPs had experience of working in medicine or neurology units. Less than a half (40.8%) had received postgraduate degree or diploma; 30.3% worked in an area outside general practice and 50.9% were affiliated with a teaching institution. Majority of the GPs (64%) had graduated in medicine within the last two decades (Table. 1).

Diagnosis and Stratification of TIA Risks: To assess the diagnostic and risk stratification abilities, GPs were asked multiple question about a 50 year old male with hypertension for 6 years and 20-pack-year smoking history who presented with tingling / numbness in left arm and left leg for 10 hours prior to presentation. On examination, patient had weakness of left side of body but speech was normal. Their answers were coded into yes, no and do not know. The majority of GPs (78.9%) and (83.8) stated patient may have had TIA or stroke respectively. A majority correctly thought that the risk of stroke in the first 48 hours was not low (63%) and that a normal CT would not exclude stroke (56.6%). Similarly, 82% of GPs said that hypertension contributed to risk of stroke in the next 48 hours and more than a half (51.8%) said duration of symptoms does not contribute to risk (Table 2a and b).

Investigations for TIA or Stroke: GPs were asked about investigation plan for a follow-up patient who had suffered a TIA with symptoms    of vertigo and ataxia 2 days earlier, symptoms had completely resolved and he had been discharged from the hospital after CT scan with no further investigations. 92 % of the GPs indicated that they would take blood tests (complete blood count, urea creatinine electrolyte, random blood sugar, lipid profile). More than half (52.6%) of the GPs wanted to repeat CT scan in 7 days. Most GPs (58%) suggested that there was no need for EEG and 64% thought that MRI was a more appropriate test than CT scan. In another question, GPs were asked whether patient required Carotid Doppler ultrasonography as symptoms were not from the carotid artery distribution area. The largest proportion of GPs (60.5%) opted for Carotid Doppler ultrasonography (Table.3).

Management of TIA: In the questionnaire, GPs were asked to select management options for TIA. Agreement was highest (79.4%) for the statements suggesting that aspirin should be started as soon as the CT scan brain excludes hemorrhage and 72% suggested to start clopidogrel alone if patient is intolerant to aspirin. More than a half (55.3%) suggested that lipid-lowering agent (statin) should be started only if the blood test revealed hypercholesterolemia. However, 40% GPs disagreed with this strategy. 44% felt, angiotensin converting enzyme (ACE) inhibitor should be started regardless of blood pressure;

43% of GPs gave negative response in respect of starting ACE inhibitors. The lowest rates (32%) of agreement were with statements that aspirin / clopidogrel should be started before a CT scan brain. 45% of GPs selected the option that anti-diabetic medication should be started or continued in diabetic patients regardless of blood glucose level. However, 41% GPs disagreed with the statement (Table.4).

 To our knowledge, this is the first survey conducted in Karachi, Pakistan, to assess the TIA and stroke-related knowledge, skills, and practices of GP. Stroke and TIA are a cause of major concern globally and in Pakistan. According to one estimate, the prevalence of TIA in Pakistan is almost twice the highest reported prevalence in the world [3]. The crude prevalence of stroke per 100,000 individuals was 246 in USA (year=1989-90;n=5201) [21],  4740 in UK (year=1993;n=2000) [22], 842 in India (year=1988;n=14010) [23], 595 in Taiwan (year=1994; n=11925) [24] and was 19,000 in Karachi Pakistan  (year=2008-2009; n=545) [3] . These high prevalence rates need an early assessment, management, and referral of TIA patients to a specialist care if required. Generally, GP is the first person who interacts with the patients before transfer to the tertiary care center. In Pakistan, there is no structured training program or workshops or refresher courses or any other way of evaluating or assessing the core knowledge or skills of GPs. TIA is a difficult diagnosis for non-neurologists. Poorly updated knowledge about TIA among non-neurologists may represent a contributing factor to the persisting sub-optimal management of patients with TIA. Hence, improved medical education of this group of health care professionals appears warranted [25]. A cross sectional study performed in GPs of Western Adelaide reported a less confident response in the selection of specific treatments in TIA with 15/32 answering correctly about the anti-hypertensive treatment [16], while our study showed a correct response of 101/228. All physicians correctly identified the early risk of stroke following a TIA [13], while our study reported 145/228 correct responses. Nearly all responded correctly regarding the appropriate blood tests to order in TIA [13], while our study showed 209/228 correct responses in hematological and biochemical investigations, 156/228 responded correctly regarding ECG, and 138/228 answered correctly regarding Carotid Doppler ultrasonography of neck vessels. The work of GPs routinely comprises of evaluation and assessment of patients in a limited time and educating them regarding their illness. Public awareness and educating people regarding early features or signs and symptoms of TIA should be done at a broader level. Our study also has several potential limitations. We did not assess GPs from other areas of Pakistan or from other countries limiting the generalizability of the study. Further, while our study assessed the knowledge of GPs, we did not observe how often GPs were able to apply their knowledge to the benefit of the patient. Lack of a concomitant control group makes it difficult to assess whether the knowledge of GPs practicing in Karachi is different from GPs in other regions. The major strength of our study is a relatively larger sample size and perfect survey response rate.

Despite no properly structured training for GPs in Pakistan, majority of the GPs appear to have good knowledge of TIA and stroke. This study concludes that with the liaison between community care and tertiary care hospitals, GPs can recognize TIA reasonably well, a major contribution to the assessment and management of TIA. It also highlights the need for further education, training and practical guidelines for GPs.

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