Post-stroke follow-up: Time to organize.

Background/objective: General practitioners (GPs) are pivotal in the organization of the entire post-stroke management system. This study aimed to examine the sequelae of chronic post-stroke patients and to assess whether the medical follow-up organized by GPs is truly in accordance with current recommendations and patients' clinical needs.

Methods: This was an observational study including chronic post-stroke patients after a first stroke. Their post-stroke follow-ups (visits to GPs and specialist doctors) were compared with guidelines and with clinical needs as evaluated through a number of questionnaires.

Results: Overall, 53.2% of patients visited a neurologist as recommended and, although 49.4% had neuropsychiatric consequences, only 6.3% visited a psychiatrist. Similarly, while 34.2% had significant post-stroke disability, only 6.3% saw a rehabilitation physician.

Conclusion: Taking into account not only cardiovascular prevention, but all post-stroke consequences, medical follow-ups as organized by GPs were not in accordance with recommendations and failed to take advantage of the currently available multidisciplinary resources required to improve patients' needs.