title: Under-prescribing of Prevention Drugs and Primary Prevention of Stroke and Transient Ischaemic Attack in UK General Practice: A Retrospective Analysis.
abstract: BACKGROUND
  Stroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused.
  
  
  RESULTS
  We analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated. In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs. The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients' adherence to medication or medication targets, such as blood pressure levels.
  
  
  CONCLUSIONS
  In our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and antihypertensive drugs is important to reduce the incidence and burden of stroke and TIA.
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Grace M
authors.identifier: http://orcid.org/0000-0002-9783-9413
authors.initials: GM
authors.lastname: Turner
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Melanie
authors.identifier: http://orcid.org/0000-0002-1856-837X
authors.initials: M
authors.lastname: Calvert
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Max G
authors.identifier: http://orcid.org/0000-0002-3891-5068
authors.initials: MG
authors.lastname: Feltham
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Ronan
authors.identifier: http://orcid.org/0000-0001-5919-3191
authors.initials: R
authors.lastname: Ryan
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Fitzmaurice
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: K K
authors.initials: KK
authors.lastname: Cheng
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Tom
authors.initials: T
authors.lastname: Marshall
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D058006:General Practice / Q000706:statistics & numerical data; D000960:Hypolipidemic Agents / Q000627:therapeutic use*; D002546:Ischemic Attack, Transient / Q000188:drug therapy / Q000517:prevention & control*; D004364:Pharmaceutical Preparations / Q000600:supply & distribution; D011322:Primary Prevention / Q000706:statistics & numerical data; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy / Q000517:prevention & control*; D006113:United Kingdom
chemical_list: D000925:Anticoagulants; D000959:Antihypertensive Agents; D000960:Hypolipidemic Agents; D004364:Pharmaceutical Preparations