Design and setting
The study took place in Møre og Romsdal County in Western Norway. This is an affluent area with good access to primary and secondary health care. In 2016 the county had the highest life expectancy for boys and the second highest for girls among all 19 Norwegian counties [
19]. In Norway, all residents are entitled to a regular general practitioner (RGP). When a resident is registered on a GP’s list of patients, the GP has the medical responsibility for this person. At the time of this study, about 99% of the Norwegian population was registered on GPs’ patient lists [
20]. When a person registered on a GP’s list is discharged from hospital, the GP normally receives a discharge summary. The discharge summary is a transfer of information from the hospital to the GP, not a formal referral. The guidelines [
2] state that discharge summaries of good quality sent to the RGP is a prerequisite for the follow-up of stroke patients.
The study included patients treated for ischemic stroke in two Norwegian local hospitals in 2011 and 2012. Patients with hemorrhagic stroke were not included. The reason for this was that the guidelines do not apply to all forms of hemorrhagic stroke. A search for the ICD-10 discharge diagnosis I63.0 trough I63.9 identified patients with cerebral infarction in the hospital files. The patients’ RGPs were identified by The Norwegian Health Economics Administration (Helfo). All patients identified in the hospital files were registered with an RGP, and all patients included had active practicing RGPs in clinics with regular office hours and availability. All clinics were available for wheelchair users, and all clinics had secretaries available by phone. All clinics also had laboratory services including availability of blood investigations such as CK, transaminases and cholesterol. The costs of laboratory services are covered by the National Insurance Scheme. Residents in Norway have compulsory membership in this scheme. None of the clinics had dietitians or rehabilitation therapists as part of their staff.
Invitation to participate in the study was sent to each of the GPs identified as described above. Only patients living in their own home and registered with an RGP who accepted participation, were subsequently invited to participate in the study. Patients in nursing homes were excluded.
One of the authors (RAaP) visited each clinic personally. All clinics kept electronic medical records, and each clinic provided access for the researcher. The GPs used three different electronic medical record systems. We evaluated the records of each consultation (
n = 381) in the RGPs’ clinic the first year after the hospital stay or the last outpatient hospital consultation. The record’s laboratory results, prescribing registries and diagnosis registries were all used to support the evaluation of the written text record of each individual consultation. An operational definitions list was used to standardize the coding of data (Additional file
1).
We noted the number of consultations with any content relevant for stroke follow-up, as was the number of consultations mainly concerning stroke. A note was made where we found that any of the lifestyle factors diet, BMI, physical activity, alcohol consumption or smoking had been addressed in the consultation. We chose to include those who had a recorded BMI, also when recorded before the specific follow-up year. Furthermore, we recorded whether or not the recommended blood tests were taken and the results of blood pressure measurements and LDL laboratory results, as these tests have specified targets in the guideline, expected to be reached.