TORONTO—The delay between symptom onset and presentation to hospital among stroke patients actually appears to be growing, according to the results of a new study. In fact, the delay is greater in the d®äAppleCD Audio Player®åiTunes®è ,Acrobat WebCapture Prefs®ê ,Acrobat WebCapture Cookies®ë ,Adobe Online Processes®ìVicomsoft FTP Client 3.1.5®î ÞNR®ïnr_sep02_window.html®ò Þnr_sep02_window.html®ó the National Stroke Association to increase the number of patients who come to the emergency department within the three–hour window required for thrombolytic therapy. Dr. Goldstein is Associate Professor of Medicine (Neurology) and Director of the Duke Center for Cerebrovascular Disease, Duke University Medical Center, Durham, North Carolina.

ARE PUBLIC EDUCATION CAMPAIGNS FAILING?

Their own institution is in the heart of what has become known as the Stroke Belt, an area of high endemic vascular disease, Dr. Goldstein said. To address this problem, they, along with other institutions across the state, have undertaken similar public awareness campaigns. To estimate the efficacy of this type of campaign, they compared the time from symptom onset to hospital arrival among patients presenting to Duke in 1998 with that of those presentingit &inationFo 1®¼ ÞMediaAwardsCrit &inationFo 1®½wëMediaAwardsLetter.pdf®¿ ÞMediaAwardsLetter.pdf®Å ,MenuFonts Data®ÒwëBABY.MPG®ÓBABY.MPG®ÕQuickTime Player®Ö ÞBABY.MPG®ÜwëBABY.MPG 1®âFiona Apple - Tidalh ischemic stroke presented within three hours of symptom onset, compared with only 8% of 272 in 1999, a highly statistically significant difference. Perhaps unsurprisingly, those with less severe strokes and younger patients had greater delays in coming to hospital. Time to presentation did not differ by race or sex. Logistic regression showed that time to presentation was independently related to both stroke severity and the year. "What that does is raise some questions about the actual effectiveness of the educational campaigns as they are currently structured," Dr. Goldstein said of their findings, "and it suggests that we haven't found the right answer for how to do this yet."

KNOWLEDGE IS NOT TRANSLATING INTO ACTION

While no reasons for the decline can be gleaned from the observational study, a number of studies they and others have carried out do give some hints. For example, he said, "there seems to be a disconnect between the patients' knowledge of stroke—their intellectual knowledge about what to do if they or somebody else is having a stroke—and what they actually do. It's that disconnect that we haven't figured out how to attack."

A few years ago, the Duke group carried out a survey within the Stroke Belt and found that while there were gaps in patient knowledge, it was "actually not all that terrible," Dr. Goldstein said. A relatively high proportion, about 71%, knew to call 911 or go to the hospital if they thought they were having a stroke, and 80% thought that stroke was a treatable condition, so there was a reason to go. "Yet, the numbers indicate that only a small proportion of people are showing up within that time, and it's actually getting worse, not better," he said.

Stroke appears to be different than other diseases, he speculated, in that intellectual knowledge about stroke symptoms or what to do when having a stroke doesn't seem to translate into appropriate action. Another national study also showed this odd "disconnect." Patients who were identified as being at higher risk for stroke, either because they had already had a stroke or transient ischemic attack or had hypertension or some other stroke risk factor, were asked whether they felt they were at elevated risk for stroke. Less than half recognized or admitted they had an elevated risk, although about a quarter of patients could recall their doctor having told them that they did.

"About 40% of the people overall said that they feared stroke worse than death, so it's not that they don't recognize or understand the potential impact of it, and it's not that they don't recognize that they may be at risk," Dr. Goldstein said. "The denial and the disconnect in this disease are a major hurdle that we have to get over, and we haven't figured out how to do that yet." He noted, though, that a variety of observations are beginning to "crystallize." But any strategy that is put forward to attack the problem will have to be tested rigorously, he added.

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