Background:
Medications can prevent stroke but are not used optimally. The overarching
aim of this thesis was to study medication use in patients with previous ischemic stroke or
transient ischemic attack (TIA) and in all patients with atrial fibrillation. Socioeconomic and
demographic factors such as sex, education, and income have been associated with
differences in medication use after stroke. Understanding these associations better may help
in understanding reasons for suboptimal medication use. In the chronic setting, patients with a
previous stroke are followed in primary care in Sweden. Primary care is thus an important
target for improving medication use. All patient visits in primary care require that a diagnosis
is recorded by the doctor in the patient’s electronic medical record. This “recording” of
diagnoses has been hypothesized as a potential quality indicator, but the utility has not yet
been proven. Also, the association between diagnosis recording and medication use has not
been studied. Audit & feedback is a commonly used approach to achieve changes in behavior
in healthcare personnel. Changing the prescribing and motivating behavior of primary care
doctors vis-à-vis stroke/TIA and atrial fibrillation patients could potentially increase
medication use.
Methods:
All the studies in this thesis were registry based and have included patients ≥18
years of age from Region Stockholm. The outcome of all studies has been medication use. By
using the Swedish National Prescribed Drug Register (NPDR), we were able to study
medication dispensation to patients as a marker of medication use. Study I used cross-linked
data from the VAL database (see below), NPDR, and Statistics Sweden. Studies II-IV used
data from the local healthcare administrative database for Region Stockholm, the VAL
database. Data in VAL is identical to that found in the National Patient Register (NPR) and
since 2010 also the NPDR. In study I we explored the association between medication use
and socioeconomic and demographic factors 9-12 months after ischemic stroke/TIA. Study II
explored the association between diagnosis recording in primary care and medication use for
the diagnoses stroke/TIA and acute coronary syndrome. Studies III and IV tested if an audit
& feedback intervention in primary care could improve medication use and diagnosis
recording in patients with ischemic stroke/TIA (III) or atrial fibrillation (IV).
Results/conclusions:
Use of recommended preventive medications in Region Stockholm has
increased over time in both patients with prior ischemic stroke/TIA and patients with atrial
fibrillation. Although statin use has increased, statins are still the secondary preventive
medication class which is used the least after ischemic stroke/TIA. The sex gap in statin use
after ischemic stroke/TIA has persisted over time and future interventions should target
improving statin use particularly in women. High income was associated with being
dispensed more statins, anticoagulants, and antiplatelets 9-12 months after ischemic
stroke/TIA. Having a diagnosis recorded in primary care was associated with greater use of
antithrombotics and statins in ischemic stroke/TIA, and acute coronary syndrome. Also,
recorded atrial fibrillation patients used more anticoagulants. An audit and feedback
intervention did not improve the utilization of preventive stroke medications in primary care