Improving Stroke Systems of Care: A Tandem Role for Neurology and Primary Care Physicians

IN JULY 2021, the American Heart Association (AHA)/American Stroke Association (ASA) released a scientific statement outlining goal-directed and patient-centered care for poststroke management in adults. Entitled “Primary Care of Adult Patients After Stroke,” the statement calls specific attention to the role of the primary care provider in the poststroke phase.

According to Mitchell S. V. Elkind, MD, MS, MPhil, immediate past president, AHA/ASA; professor of neurology and epidemiology, and chief, Division of Neurology Clinical Outcomes Research and Population Sciences, Columbia University, the guidance is a useful tool for the primary care community, as they are generally more involved with patient care than neurologists are following a stroke, playing a pivotal role in educating patients, as well as controlling risk factors and associated complications such as depression and other mental health issues.

To find out more about the role that primary care can play and the need for communication and interplay between them and neurologists, NeurologyLive® spoke with Elkind about the AHA/ASA’s position.

Q: What should the clinical community take away from the recent AHA/ASA statement?

This statement is really about the role of the primary care provider in the care of the patient with stroke after they recover from their initial stroke and return home. It’s about how primary care physicians can play an essential role in the treatment of patients with stroke going forward. There’s a tremendous amount that primary care physicians can do.

First, most patients with stroke are cared for by primary care physicians, not by neurologists, especially in the long term. Primary care doctors are going to have a very important role in helping patients understand their new disabilities, if that’s the case, and their new life after stroke. They’re going to have an important role to play in controlling peoples’ risk factors, managing their medications to prevent them from recurrences, and managing some of the complications that can occur after somebody has a stroke, [such as] depression or other mental health problems, cognitive issues, or symptoms like pain and discomfort.

This statement is about explaining to that community how they can best help their patients going forward. Primary care doctors are in a great position to help patients who’ve had a stroke because stroke goes along with a lot of other chronic medical problems that primary care doctors are probably the best equipped to deal with. Conditions like high blood pressure, diabetes, high cholesterol—these are all very common, of course, in patients with stroke. Those physicians are well equipped to help patients manage this. They also know these patients well. They know their family situation, social situation, and employment situation, so they’re able to help their patients navigate through those kinds of issues. This statement is really a tool to help the primary care community in their care of these patients.

Q: How can the cerebrovascular community help the primary care community have a bigger role and understand their part in the poststroke care process?

In neurology, we think sometimes about something we call neurophobia, which is this idea that people who aren’t neurologists are scared of the brain, that it’s somehow too complicated and they just don’t want to know anything about it. But a lot of what primary care doctors are doing is very fundamental to the care of patients with stroke already. There are a lot of basic care issues like management of blood pressure, management of diabetes, management of lipids, management of some cardiac conditions like atrial fibrillation, and recommending exercise and a healthy diet—these things are all essential to stroke prevention and, really, brain health overall. Primary care physicians are already in a good position to do this kind of thing.

The new stroke prevention guidelines that recently came out, and one of the new developments in those guidelines, is the idea that stroke systems of care are effective in not only managing acute stroke but also in long-term prevention. A big development over the past couple of decades has really been this idea that we need to get patients into the emergency [department] right away when they have a stroke to be able to give them clot-busting medications like tPA [tissue plasminogen activator] or thrombectomy, extracting a clot from the brain. Our stroke systems of care were focused on prehospital care, the emergency [department], and those kinds of acute interventions. But stroke systems of care are also important for the transition from the acute hospital to rehabilitation, back to the home, and then the longterm care of the patient.

There are ways in which the acute neurological care of the patient, and the neurology team, can help the secondary care provider and the primary care provider afterward. For example, things like checklists that people can use after they go back to their primary care provider can be useful to set up a plan to manage patients going forward, and then use that as a reference point to make sure that the care is consistent with that plan. With the evidence-based guidelines that exist, opportunities for the primary care physician to speak with the neurologist and the neurology team and make sure that transition is smooth exist, too, so that everybody knows what medications the patient is being discharged on. In some cases, the medications need to be adjusted or changed. For example, people often get discharged from the hospital now on dual antiplatelet therapy. We know that combination works to reduce risk but shouldn’t be continued indefinitely—its benefits are there up to about a month or so. After that point, patients should probably be transitioned to a single agent. It’s important for that information to get from the neurology team in the acute setting to the secondary care or a primary care provider afterward. Some of the patient evaluation also may not be completed during the initial hospitalization. The evaluation for atrial fibrillation, for example, can require long-term monitoring of the patient after they leave the hospital. All that information needs to be transmitted to the primary care provider after they leave, and I think that’s part of having an ideal stroke system of care set up.

Q: How would you describe the state of education on stroke care among primary care providers?

Primary care providers know how to manage a lot of the conditions that are so central to the cause of stroke and to preventing stroke recurrence. They’re really the experts at speaking with patients about the use of medications to address their high blood pressure, blood sugar issues, and cholesterol levels. They’re also experts at addressing issues like adherence. They’re good at getting information from patients about adverse effects that they may be having but maybe not sharing with other physicians, like their neurologist, for example. They may be able to help people understand their medications better and adjust their use of those medications. Primary care providers are also the ones that we turn to when we have questions about lifestyle issues: What kind of diet should I have? How can I get enough exercise? They’re ideally positioned to help with a lot of those kinds of questions that are fundamental to people’s health, and not only to their risk of stroke, of course, but also to their risk of cardiac disease or other vascular disease throughout the body. These are things that the primary care physicians can certainly make a major contributions to, for their patients.

There are some things that are specific to stroke care. After stroke, for example, people are at risk of developing depression—about one-third of patients will develop depression after a stroke. This is also something that primary care physicians are attuned to and know to look for. Anxiety can [also] be a big problem. Even posttraumatic stress disorder occurs after an acute event like a stroke. [Then] there are some problems that may be a little bit less familiar to primary care doctors—[for example], certain pain syndromes like the frozen shoulder syndrome that some people get when they develop hemiparesis and they can’t move their arm, with the shoulder becoming painfully tight and stiff. That can be an issue that may be less common in the primary care practice. Similarly, central pain syndromes and certain types of stroke leave people with pain in different parts of the body. That can be confusing because one may go looking for alternative explanations of the pain rather than the stroke. For example, with spasticity or spasms of the limbs after a stroke and a paralyzed arm, some people may have pain or jerking movements of the weak limb. These may be things also that the primary care physician may want to turn to a neurologist, a physiatrist, or a rehabilitation specialist for help with. There are things like that, which I think the primary care community would benefit from more education about, at least so that they can recognize those problems in those syndromes and then be able to refer people back for specialty care to specifically manage and address them.

Q: How important is it to have established systems of care in stroke?

[They] have become so important in all that we do. We recognize that when systems fall short, for example, when structural racist systems are in place, they help to facilitate disparities and inequities in health care. Those are bad systems. They make resources less available to certain groups of people compared with others. Conversely, we can make a choice to make better systems that facilitate medication availability, insurance availability, adherence to medications, and healthy environments...and so forth. What we need to do is not put all the pressure on the individual patient and the physician but create systems that can be facilitated by hospitals and accountable care organizations that make health care easier to provide for all of us.