This cross-sectional study provides an overview of AF detection by neurologists in real-word clinical practice among cryptogenic stroke patients in Hubei province in China. The main findings of this survey were that: 1) Almost all of the neurologists knew the stroke risk of AF, but only 53% of them would always detect AF in cryptogenic stroke patients; 2) The main obstacles of AF detection were insufficient knowledge, high expense, inactive attitude, tense doctor-patient relationship and equipment deficiency; 3) Neurologists’ attitude and continuing medical education were important factors influencing AF detection behavior.
AF detection in initially diagnosed cryptogenic stroke patient was well emphasized and recommended by clinical guidelines [17, 19–22]. However, only 53.0% of the respondents would always detect AF in cryptogenic stroke patients, forming a substantial gap between management recommendations and everyday clinical practice, even though almost all the neurologists in this survey knew the high recurrence risk of stroke associated with AF. Consisting result was found by Giruparajah, M. et al in a survey to physicians all over the world that only 58% of physicians globally and 36% of physician in East Asia and the Pacific region would detect AF in cryptogenic stroke patients as recommended . Comparing to recent study among cardiologists, the neurologists we surveyed had a higher awareness of health threat posed by AF, but their perception of the relationship between AF and stroke was not accurate. 59.6% of them thought paroxysmal AF had higher risk of stroke than persistent AF, incorrectly estimating the risk of different types of AF. Thus, there is an insufficient knowledge of neurologists about AF in developing country, and continuing medical education may be benefit to solve this problem.
The main obstacle to AF detection in patients with cryptogenic stroke was once thought to be the deficiency of detecting equipment. However, this survey revealed that deficient knowledge was the first of all the changeable causes. 27.9% of respondents regarded the insufficient knowledge as the major obstacle, and 13.1% of them attribute it to the inactive attitude, both of which could be overcome by continuing medical education. More education program about AF detection for neurologists is warranted. 12.3% of respondents attributed the major obstacle to tense doctor-patient relationship. The tense relationship may be partly caused by the misunderstanding between doctors and patients about AF screening, especially healthcare professionals, particularly general practitioners are as the most important medical information source of patients. Public continuing medical education about cryptogenic stroke associated with AF will be helpful. 24.0% of them ascribed it to high expense of AF detection. Indeed, medical decision-making are always limited to patient's medical burden and affordability in China, as current government medical input only accounts for 4.6% of gross national product (GNP) for the health of 1.4 billion people, 22% of the world’s population. Thus, Chinese government should increase health support, decrease medical economic burden, and improve the efficiency and quality of health insurance[25, 26].
The survey revealed that positive attitude, continuing medical education (AF detection training), and master degree were important influencing factors of AF detection behavior, and the most powerful factor was neurologists’ attitude (OR = 3.25, CI[2.24, 4.71], p < 0.001). Neurologists having positive attitude would more likely to do AF detection. Furthermore, positive attitude of AF detection was found to be associated with long working duration (over 20 years) and continuing medical education about AF detection. Actually, the survey highlighted that even for those who did not acquire high academic degree and who had a short working duration, continuing medical education about AF detection would promote neurologists’ attitude and behavior. Neurologists receiving continuing medical education may be more familiar with current guideline recommendations, more aware of the risk of AF associated stroke, and do AF detection more frequently as recommended. Physicians’ knowledge are cornerstone for evidence based practice, effective treatment and disease prevention. Previous studies also found that continuing medical education for clinicians would improve medical quality and patients outcome[28, 29]. Besides, the association between positive attitude and long working duration could be partly explained by more chances to receive continuing medical education about AF. Thus, continuing medical education was most important to improve AF detection in cryptogenic stroke patients, and more continuing education about AF are required.
There are several limitations to this study. First, neurologists from each hospital was voluntary and those who responded to the surveys may be more knowledgeable about current recommendations than those declined, thus response bias may exist. Second, respondents may reported the ‘correct’ answer which did not reflect their actual clinical practice as knowledge is not always translated into action, which may cause social desirability bias. Third, this study was conducted in hospitals from one medium development central province in China. Findings of this study need to be verified in other areas in China.