Medical Attention Seeking After Transient Ischemic Attack and Minor Stroke Before and After the UK Face, Arm, Speech, Time (FAST) Public Education Campaign

This population-based study investigates the association of public education with improving delays and failure in seeking medical attention among consecutive patients with first transient ischemic attack or stroke.

W hen left untreated, approximately 5% of patients with transient ischemic attack (TIA) or minor stroke have a major stroke within 24 hours, comprising more than 40% of all recurrent strokes within 30 days. 1 Urgent investigation and medical treatment substantially reduce risk of early recurrent stroke, 2,3 as could initial selfmedication with aspirin alone. 4 Consequently, guidelines recommend that patients with high-risk TIA should be assessed urgently. [5][6][7] However, patients frequently fail to recognize or act on TIA symptoms, either delaying seeking medical attention 8,9 or not seeking medical attention at all. 10,11 The number of potentially preventable early recurrent strokes that consequently go unprevented is unknown, although recent public education campaigns designed to increase recognition of major stroke symptoms might change behavior after TIA.
The Face, Arm, Speech, Time (FAST) test was adopted as a tool to improve symptom recognition after stroke 12, 13 and has formed the basis of public education in many countries, including the United Kingdom, Ireland, United States, Australia, and New Zealand, with variants in several non-English-speaking countries. The FAST test was used in an ongoing television public awareness campaign in the United Kingdom from 2009 onward. It appears to have improved the response after major stroke, 14-17 but the association of the campaign with patient behavior after TIA and minor stroke has not been determined and may well differ given differences in event duration, severity, and coverage by the FAST acronym.
We prospectively studied patient perception and behavior after TIA and stroke in a population-based study before and during the ongoing FAST campaign. We also investigated the number of early strokes after a TIA for which no medical attention is sought.

Ethical Approval
The Oxford Vascular Study (OxVasc) was approved by the Oxfordshire Research Ethics Committee and included use of routinely collected health care data for investigating incidence rates without consent. Written informed consent or assent was obtained from all participants for additional data.

Study Design
The OxVasc is a population-based study of all acute vascular events, including TIA and stroke in 92 728 individuals of all ages registered with 100 collaborating primary care physicians at 9 general practices in Oxfordshire, United Kingdom. The OxVasc study methods have been described previously 18 and are recounted in the online methods (eFigure in the Supplement). The present article includes all consecutive incident TIA and stroke cases, with the exception of subarachnoid hemorrhages, occurring outside the hospital between April 1, 2002, andMarch 31, 2014. Data analysis took place from July 1, 2013, to March 2, 2015.
Most patients were seen in the dedicated study TIA and stroke clinics or were admitted to the acute stroke service at the principal center (John Radcliffe Hospital, Oxford, United Kingdom) serving the study population. Patients provided informed consent (or assent was obtained from relatives) and were seen by study physicians (among whom were F.J.W., L.L., and P.M.R.) for structured interview using a standard questionnaire as soon as possible after initial presentation to assess their perception about the event and immediate response to symptoms, including date and time of symptom onset, when medical attention was sought and by whom, the first contact with emergency medical services (EMS), and why they did not seek medical attention straightaway in case of delay to medical attention exceeding 3 hours. Patients were routinely questioned about any neurological symptoms within 90 days before their presenting event (ie, unheeded TIAs) and were followed up for recurrent cerebrovascular events (eFigure in the Supplement). 18 Baseline characteristics, including demographic data, selfreported race/ethnicity, and risk factors for stroke (based on prior diagnosis and current medication use), were recorded, and assessments were made for severity of the event using the National Institutes of Health Stroke Scale. Major stroke was defined as a National Institutes of Health Stroke Scale score exceeding 3. Socioeconomic status was assessed according to the United Kingdom's 2007 indexes of deprivation. 19 Based on these indexes, the electoral districts covering our population are less deprived than the rest of the United Kingdom, but still 22% of our districts rank in the lower one-third nationally. Further data were acquired from medical records, ambulance sheets, general practitioner referral letters, and consultation notes. Consent for access to this information was obtained from all participating patients.
To best reflect the response of patients to symptoms, time of symptom onset was defined as time of awaking if onset of stroke was during sleep. In patients unable to call for help, time of symptom onset was considered the moment another person noted their symptoms. Events were classified as FAST positive when at least one symptom from the FAST campaign

Key Points
Questions What is the number of potentially preventable early recurrent strokes in the United Kingdom among patients who delay or fail to seek medical attention, and has extensive public education changed patient response?
Findings Among 2243 consecutive patients with transient ischemic attack or stroke in this population-based study, extensive Face, Arm, Speech, Time (FAST)-based public education has not improved the response to transient ischemic stroke and minor stroke. The percentage of strokes preceded by a transient ischemic attack for which no attention was sought remained unchanged.
Meaning Public education campaigns tailored to transient and less severe symptoms are needed to encourage urgent patient response to imminent stroke warning signs.
(ie, facial weakness, arm weakness, or speech disturbance) was present at symptom onset.

FAST Campaign in the United Kingdom
The initial FAST public education television campaign in the United Kingdom ran from February through April 2009, with 8 weeks of national television broadcasts. With initiation of the 2009 campaign, the T in FAST was redesignated "Time to call 999" (ie, EMS) rather than "Test all 3." Repeated television campaigns ran intermittently for several weeks from

Statistical Analysis
Analyses included all first TIA and first stroke occurring outside of the hospital during the study period, with the exception of analyses of patient perception, which excluded patients with reduced consciousness, event-related confusion, or dysphasia. We analyzed patient behavior before April 1, 2009, and after April 1, 2009 (ie, the end of the first major 2-month television campaign) and stratified the analyses (ie, assessed behavior per year of the study) into study years. To assess any association of the FAST campaign with the number of strokes in our study population that could potentially have been prevented by urgent patient behavior after initial symptoms of a TIA, we assessed the number of all 90-day recurrent ischemic strokes preceded by an unheeded TIA. Together with all 90-day recurrences after heeded events, these constitute all early recurrent strokes. We compared the unheeded TIAs with the TIAs in patients who sought medical attention and extrapolated the OxVasc population rates (number of unheeded TIAs divided by the OxVasc source population per 10 years) to the general population to estimate the number of potentially preventable strokes after unheeded TIAs annually.
Time from TIA or stroke symptom onset to first seeking medical attention and the nature of the first medical attention sought-defined as emergency (ie, direct contact with ambulance services or presentation to an emergency department) vs nonemergency (ie, the first contact with a general practitioner or other local health care professional)-were also compared before vs after April 1, 2009, within clinically relevant timing cutoffs of 3 and 24 hours by performing χ 2 test and computing Mantel-Haenszel test odds ratios (ORs). To further assess time trends, the first contact with EMS vs non-EMS was analyzed per year of the study. Subsequent adjustment was made for time trends and age, sex, race/ethnicity, socioeconomic status, cohabitation, National Institutes of Health Stroke Scale and ABCD2 (age, blood pressure, clinical features of the TIA, duration of symptoms, and history of dia-betes) scores, onset during sleep, and occurrence during the weekend 20 by means of segmented regression analysis, 21 breaking down time to months and again using April 1, 2009, as the change point. Missing data for covariates in this model were imputed (eTable 1 in the Supplement). We formally assessed for differential associations of the FAST campaign by event type (TIA and minor stroke vs major stroke) by testing for multiplicative interaction in the fully adjusted time-series regression model.
We assessed the association of perception (classified as correct [ie, TIA, stroke, or ministroke] vs incorrect) with subsequent behavior, as well as the proportion of patients with correct initial perception of symptoms before vs after April 1, 2009, in relation to presence of FAST symptoms. Finally, we repeated the trends analyses, comparing only the 5 years immediately before April 1, 2009, vs the subsequent 5 years. All analyses were performed using a software program (SPSS Statistics, version 21.0; IBM). Two-sided α level (type I error) was set at .05.

Results
Among 2243 consecutive patients with first TIA or stroke in the study period (mean [SD] age, 73.6 [13.4] years; 1126 [50.2%] female; 96.3% of white race/ethnicity), 825 (36.8%) were initially seen with TIA, 831 (37.0%) with minor stroke, and 587 (26.2%) with major stroke. Baseline characteristics of patients (1231 pre-FAST and 1012 post-FAST) are listed in eTable 1 in the Supplement. Data on who sought medical attention were available in 2003 patients (89.3%), and data on first clinician were available in 2196 patients (97.9%). Time from event to call for medical attention and hospital arrival was unknown in 209 patients (9.3%), most commonly because of unconsciousness, dysphasia, dementia, or early death and unavailability of an alternative informant.

Weekend Presentation
Patients with TIA or minor stroke were seen less often during the weekend, with higher numbers initially seen directly after the weekend (Figure 1). For major stroke, presentation was similar throughout the week. Weekend presentation of TIA or minor stroke vs major stroke was 267 of 1537 (17.4%) vs 155 of 575 (27.0%) (OR, 0.57; 95% CI, 0.45-0.71; P < .001). These findings were similar before and after April 1, 2009.  Figure 2C). The observed association of the FAST campaign with response to TIA and minor stroke differed significantly from the association with response to major stroke for both use of EMS (P for interaction in the timeseries analysis = .03 vs major stroke) and time to first seeking medical attention within 24 hours (P for interaction in the timeseries analysis = .006 vs major stroke). Results were similar for TIA and minor stroke and when restricting analyses to 5 years before and 5 years after initiation of the campaign.

Stroke After Unheeded TIAs
Ninety-five patients who had sought attention for an initial TIA or stroke had a first or recurrent stroke by 90-day follow-up. In addition, 93 patients with stroke reported having symptoms of a TIA for which they had not sought medical attention during the 90 days before their presenting stroke. Therefore, there were 188 early strokes after initial TIA or stroke in all patients, in whom 93 (49.5%) occurred after a TIA for which no medical attention was sought. This number of strokes preceded by an unheeded

Discussion
In contrast to major stroke, we found in this study that for TIA and minor stroke the UK nationwide televised FAST campaign has not improved patient use of EMS or patient delay in seeking medical attention. Moreover, the percentage of strokes that followed shortly after an initial TIA for which no medical attention was sought remained unchanged after the FAST campaign, representing approximately 100 potentially preventable strokes per 1 million inhabitants annually. It is likely that many individuals experience transient neurological symptoms for which they do not seek medical attention and do not have stroke. The results of large randomly dialed telephone studies 10,11 have suggested that approximately 15% of people in the general population had experienced transient neurological symptoms during the previous few years, such as weakness, numbness, or visual problems. Although we cannot determine the total number of unheeded TIAs in our study population, we found that the share of strokes preceded by symptoms suggestive of TIA in the community for which no medical attention is sought has remained unchanged after the FAST campaign, affirming that these ignored events are an important target for stroke prevention. The large number of patients with TIA during the weekend who seek medical attention only days later during office hours emphasizes that less severe or shorter-lasting symptoms are not thought to require immediate medical attention, with no reduction since the FAST campaign. Seventy-five percent (70 of 93) of patients with stroke after unheeded TIAs were not taking antithrombotic medication, highlighting the missed opportunity for secondary prevention. [2][3][4] Given the high effectiveness of preventive strategies within the first hours and days after TIA, 4 the influence of public education will depend largely on its ability to convince patients to take action within this crucial window of time.
Use of EMS has repeatedly been shown to be one of the most important factors in early hospital arrival after TIA and minor stroke. 8,9,22,23 We observed no positive association of the FAST television campaign with presentation via EMS after TIA and minor stroke. Even when patients attributed their symptoms to stroke, still less than one-third (130 of 458) contacted EMS, which is in line with the findings of a 2012 UK survey. 24 Studies 14-17 have indicated a moderate influence of public education on presentation after stroke, but no published studies to date have assessed the effect of large public education campaigns on presentation after TIA and minor stroke. Compared with major stroke, one of the main differences we found in the response to TIA and minor stroke is the high association of symptom recognition with subsequent behavior in the latter. While severe symptoms require medical aid regardless of their cause, transient or minor symptoms may leave room for deliberation and attribution of symptoms to other (less worrisome) causes. A population-based survey in the United Kingdom recently showed that, despite recall of the FAST campaign, recognition and the response to hypothetical stroke scenarios did not improve. 25 The decline in correct recognition of symptoms that we observed after extensive FAST-based public education campaigns suggests that patients may be falsely reassured when their symptoms do not match the more severe symptoms depicted in public education advertisements. 26 The limited sensitivity of the FAST acronym for TIA and minor stroke (approximately 60% vs 95% for major stroke based on the Results section herein) may further explain the lack of positive influence of the campaign in this group of patients and emphasizes the need for adapted forms of public education.

Limitations
Although we believe that our findings are valid and should guide future public education, there are some limitations. First, the retrospective diagnosis of unheeded TIAs preceding stroke is inevitably subjective and may be subject to recall bias. However, we applied the same diagnostic criteria that we apply when making a diagnosis acutely after a TIA, and we will have underestimated unheeded TIAs preceding major stroke in patients who were unable to report these because of drowsiness, dysphasia, or dementia. Moreover, although we allowed a 90-day cutoff for preceding TIA to limit recall bias of distant events, most TIAs occurred within the week before the stroke and mirrored previous prospective investigations of the natural history of stroke risk after TIA. 1 Second, we did not record the diagnostic perception of bystanders or relatives, nor did we directly ask about individual exposure to and awareness of the campaign. Third, increased but slow presentation of otherwise nonpresenters after the FAST campaign may have biased time trends of TIA and minor stroke toward the null. Fourth, in view of the small fraction of people in our study who were of nonwhite race/ethnicity, our results may not be fully applicable to racial/ethnic minorities, who have previously been reported to delay to presentation longer. 8

Conclusions
In our study, a lack of improvement in patient response to TIA and minor stroke was found after extensive FAST-based public education television campaigns in the United Kingdom. This highlights the need for effective public education to be tailored to transient and minor stroke symptoms, as well as major stroke.