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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Lim A, Rothwell PM, Li L, Coutts SB, Hill MD, Guarino M, Barone V, Rondelli F, Kleinig T, Cornell-Farrow R, Krause M, Wronski M, Singhal S, Ma H, Phan TG. Rapid outpatient transient ischemic attack clinic and stroke service activity during the SARS-CoV-2 pandemic: a multicenter time series analysis. Front Neurol 2024; 15:1351769. [PMID: 38385034 PMCID: PMC10879819 DOI: 10.3389/fneur.2024.1351769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024] Open
Abstract
Background and aim Rapid outpatient evaluation and treatment of TIA in structured clinics have been shown to reduce stroke recurrence. It is unclear whether short-term downtrends in TIA incidence and admissions have had enduring impact on TIA clinic activity. This study aims to measure the impact of the pandemic on hospitals with rapid TIA clinics. Methods Relevant services were identified by literature search and contacted. Three years of monthly data were requested - a baseline pre-COVID period (April 2018 to March 2020) and an intra-COVID period (April 2020 to March 2021). TIA presentations, ischemic stroke presentations, and reperfusion trends inclusive of IV thrombolysis (IVT) and endovascular thrombectomy (EVT) were recorded. Pandemic impact was measured with interrupted time series analysis, a segmented regression approach to test an effect of an intervention on a time-dependent outcome using a defined impact model. Results Six centers provided data for a total of 6,231 TIA and 13,191 ischemic stroke presentations from Australia (52.1%), Canada (35.0%), Italy (7.6%), and England (5.4%). TIA clinic volumes remained constant during the pandemic (2.9, 95% CI -1.8 to 7.6, p = 0.24), as did ischemic stroke (2.9, 95% CI -7.8 to 1.9, p = 0.25), IVT (-14.3, 95% CI -36.7, 6.1, p < 0.01), and EVT (0, 95% CI -16.9 to 16.9, p = 0.98) counts. Proportion of ischemic strokes requiring IVT decreased from 13.2 to 11.4% (p < 0.05), but those requiring EVT did not change (16.0 to 16.7%, p = 0.33). Conclusion This suggests that the pandemic has not had an enduring effect on TIA clinic or stroke service activity for these centers. Furthermore, the disproportionate decrease in IVT suggests that patients may be presenting outside the IVT window during the pandemic - delays in seeking treatment in this group could be the target for public health intervention.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Peter M. Rothwell
- Wolfson Center for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Linxin Li
- Wolfson Center for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Shelagh B. Coutts
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Michael D. Hill
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Barone
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | | | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Martin Krause
- Department of Neurology, Royal North Shore Hospital and Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Miriam Wronski
- Department of Neurology, Royal North Shore Hospital and Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Shaloo Singhal
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Melbourne, VIC, Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Melbourne, VIC, Australia
| | - Thanh G. Phan
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Melbourne, VIC, Australia
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Roy A, Sreekrishnan A, Camargo Faye E, Silverman S, Zachrison KS, Harriott AM, Matiello M, Manzano GS, Prasanna M, Nedelcu S, Singhal AB. Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke. Neurol Clin Pract 2023; 13:e200209. [PMID: 37829551 PMCID: PMC10567120 DOI: 10.1212/cpj.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
Background and Objectives Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. Methods As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. Results We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Discussion Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.
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Affiliation(s)
- Alexis Roy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anirudh Sreekrishnan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Erica Camargo Faye
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kori S Zachrison
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mrinalini Prasanna
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Simona Nedelcu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Rossi LP, Granger BB, Bruckel JT, Crabbe DL, Graven LJ, Newlin KS, Streur MM, Vadiveloo MK, Walton-Moss BJ, Warden BA, Volgman AS, Lydston M. Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association. Circulation 2023; 148:512-542. [PMID: 37427418 DOI: 10.1161/cir.0000000000001141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.
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Shahjouei S, Seyedmirzaei H, Abedi V, Zand R. Transient Ischemic Attack Outpatient Clinic: Past Journey and Future Adventure. J Clin Med 2023; 12:4511. [PMID: 37445546 DOI: 10.3390/jcm12134511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
A transient ischemic attack (TIA), a constellation of temporary neurological symptoms, precedes stroke in one-fifth of patients. Thus far, many clinical models have been introduced to optimize the quality, time to treatment, and cost of acute TIA care, either in an inpatient or outpatient setting. In this article, we aim to review the characteristics and outcomes of outpatient TIA clinics across the globe. In addition, we discussed the main challenges for outpatient management of TIA, including triage and diagnosis, and the system dynamics of the clinics. We further reviewed the potential developments in TIA care, such as telemedicine, predictive analytics, personalized medicine, and advanced imaging.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA 17033, USA
- Department of Neurology, Neurosurgery, and Translational Medicine, Barrow Neurological Institute, St. Joseph Hospital, Phoenix, AZ 85013, USA
| | - Homa Seyedmirzaei
- School of Medicine, Children's Medical Center Hospital, Tehran University of Medical Sciences, Dr. Qarib St., Tehran 14155-34793, Iran
- Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Keshavarz Blvd., Tehran 14166-34793, Iran
| | - Vida Abedi
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Ramin Zand
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA
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Zeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health 2023; 25:181-189. [PMID: 35652977 DOI: 10.1007/s10903-022-01368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/08/2022] [Accepted: 05/04/2022] [Indexed: 01/07/2023]
Abstract
AIMS Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.
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Affiliation(s)
- Amy J Zeidan
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA.
| | | | - Rebecca Leff
- Department of Emergency Medicine, Mayo Clinic, New York, USA
| | - Alexis Cordone
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA
| | | | - Pooja Agrawal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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Grimley RS, Collyer T, Dewey HM, Andrew N, Cadilhac DA. Stroke and emergency department re-presentation after outpatient TIA management: An interrupted time series study. J Stroke Cerebrovasc Dis 2023; 32:106900. [PMID: 36427470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the effects of a non-admitted management pathway following emergency department (ED) presentation with suspected TIA on: 90-day stroke and ED re-presentations, overnight admission, length of stay (LOS) and costs. METHODS We implemented a management pathway across an Australian regional health service (4 hospitals; 2 rural, 10,000 km2) including ED protocols followed by urgent outpatient review or telemedicine consultation to one rural hospital. Interrupted time series analysis was conducted on linked hospital administrative datasets for all ED TIA diagnoses 5 years before and 2 years after intervention (2015). We assessed whether pathway introduction was associated with immediate change (level) or subsequent rate of change (slope) in outcomes. RESULTS There were 2031 presentations: 1,467 before, 564 after implementation. Against background declining trends, overnight admissions decreased by 12.4% (95%CI 5.0, 19.7) and total LOS decreased 6 hours (95%CI 1.5, 10.4). Hospital costs reduced by AUD683 per patient with implementation. Outpatient review occurred for 36% at median 5 days (IQR 3, 9), including 19/87 (22%) telemedicine reviews. Pathway adherence was incomplete: 29% had no specialist review. Recurrent stroke increased by 1.3/100 presentations (95%CI 0.6, 2.1) with implementation, then returned to baseline of 0.9/100. ED re-presentations rose at a significant rate after implementation (extra 1.69/100 patients re-presenting/quarter; 95%CI 0.8, 2.6) reaching 32/100. CONCLUSIONS An ED TIA management pathway designed to avoid hospital admission resulted in decreased hospital use and costs; but an initial increase in recurrent stroke and sustained rise in ED re-presentation, possibly related to delayed and incomplete follow-up.
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Affiliation(s)
- Rohan S Grimley
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Griffith University, School of Medicine, Birtinya, Australia; Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.
| | - Taya Collyer
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Australia.
| | - Helen M Dewey
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Box Hill, Australia.
| | - Nadine Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia; Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Australia.
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia; Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Vic, Australia.
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Low-to-Moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From the Emergency Department to a Nurse Practitioner-Led Clinic. J Neurosci Nurs 2022; 54:231-236. [PMID: 36179660 DOI: 10.1097/jnn.0000000000000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT BACKGROUND: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. The purpose of this quality improvement project was to determine whether the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. METHODS: The sample included all adults presenting to the emergency department with TIA at a low-to-moderate risk for stroke. Risks were defined by the ABCD2 score and noninvasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within 7 days. These patients were compared with those who were admitted before clinic launch. Medical record reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. RESULTS: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic and admission groups were 72.8 and 75.2 years, respectively (P = .37). Women comprised 45% of patients in the clinic group, compared with 51.2% in the admission group (P = .58). The mean ABCD2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively (P = .63). The median clinic follow-up time was 6 days. There was no stroke incidence in the clinic group and 1 in the admission group within 90 days post TIA. Patient satisfaction score metrics for the NP exceeded the institutional benchmark of 90%. CONCLUSION: Referral to an NP-led clinic in patients with low- to moderate-risk TIA was equally safe as hospital admission.
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Shah K, McCabe B, Mathews C, Nehamkin A, Desai SM, Jadhav AP. Expedited management of low-risk transient ischemic attack patients: The “Fast-Track” TIA protocol. J Stroke Cerebrovasc Dis 2022; 31:106522. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 10/18/2022] Open
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Timpone VM, Reid M, Jensen A, Poisson SN, Patten L, Costa B, Trivedi PS. Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging. J Am Coll Radiol 2022; 19:957-966. [PMID: 35724735 DOI: 10.1016/j.jacr.2022.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge. METHODS Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression. RESULTS In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI. CONCLUSIONS Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.
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Affiliation(s)
- Vincent M Timpone
- Director, Stroke and Vascular Imaging and Co-Director, Neuroradiology, Spine Intervention Service, Department of Radiology, University of Colorado Hospital, Aurora, Colorado.
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colorado
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Sharon N Poisson
- Director, Vascular and Stroke Research Fellowship, Department of Neurology, University of Colorado Hospital, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Premal S Trivedi
- Director, Health Services Research, Department of Radiology, University of Colorado Hospital, Aurora, Colorado
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Effects and Satisfaction of Comfort Nursing plus Psychological Nursing in the Clinical Nursing of Neurology Patients: A Comparative Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:8013787. [PMID: 35664947 PMCID: PMC9159892 DOI: 10.1155/2022/8013787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/24/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the effects and satisfaction of comfort nursing plus psychological nursing in the clinical nursing of neurology patients. Methods In this prospective study, 90 neurology patients admitted to our hospital from January 2019 to January 2020 were recruited and randomized into a control group and an experimental group with 45 cases in each group. The control group received routine care, and the experimental group received comfort care plus psychological care. The comfort scores and nursing satisfaction of the two groups were compared. The Hospital Anxiety and Depression Scale (HAD) was used to assess the emotional state of patients before and after the intervention. The Exercise of Self-care Agency Scale (ESCA) was used to assess the patient's self-care ability after the intervention. Results The comfort scores of the experimental group were higher than those of the control group (P < 0.05). The experimental group showed significantly higher satisfaction than the control group (P < 0.05). Patients in the experimental group had lower HAD scores after intervention than those in the control group (P < 0.05). After the intervention, the experimental group had higher ESCA scores and a higher Barthel index than the control group (P < 0.05). Conclusion Comfort nursing plus psychological care improves nursing satisfaction and self-care ability of neurology patients and relieves their negative emotions.
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Ischemic Stroke and SARS-CoV-2 Infection: The Bidirectional Pathology and Risk Morbidities. Neurol Int 2022; 14:391-405. [PMID: 35645351 PMCID: PMC9149929 DOI: 10.3390/neurolint14020032] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 12/12/2022] Open
Abstract
Stroke is a fatal morbidity that needs emergency medical admission and immediate medical attention. COVID-19 ischemic brain damage is closely associated with common neurological symptoms, which are extremely difficult to treat medically, and risk factors. We performed literature research about COVID-19 and ischemia in PubMed, MEDLINE, and Scopus for this current narrative review. We discovered parallel manifestations of SARS-CoV-19 infection and brain ischemia risk factors. In published papers, we discovered a similar but complex pathophysiology of SARS-CoV-2 infection and stroke pathology. A patient with other systemic co-morbidities, such as diabetes, hypertension, or any respiratory disease, has a fatal combination in intensive care management when infected with SARS-CoV-19. Furthermore, due to their shared risk factors, COVID-19 and stroke are a lethal combination for medical management to treat. In this review, we discuss shared pathophysiology, adjuvant risk factors, challenges, and advancements in stroke-associated COVID-19 therapeutics.
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Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
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14
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Wechsler PM, Parikh NS, Heier LA, Ruiz E, Fink ME, Navi BB, White H. Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond. Neurohospitalist 2022; 12:38-47. [PMID: 34950385 PMCID: PMC8689541 DOI: 10.1177/19418744211000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients' care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.
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Affiliation(s)
- Paul M. Wechsler
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S. Parikh
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Linda A. Heier
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Evelyn Ruiz
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Matthew E. Fink
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B. Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Halina White
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA,Halina White, Department of Neurology, Weill Cornell Medicine, 520 E 70th St, Starr 607, New York, NY 10021, USA.
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15
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Luengo-Fernandez R, Li L, Silver L, Gutnikov S, Beddows NC, Rothwell PM. Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study. Stroke 2021; 53:488-496. [PMID: 34706563 PMCID: PMC8785519 DOI: 10.1161/strokeaha.121.034279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Urgent assessment aimed at reducing stroke risk after transient ischemic attack or minor stroke is cost-effective over the short-term. However, it is unclear if the short-term impact is lost on long-term follow-up, with recurrent events being delayed rather than prevented. By 10-year follow-up of the EXPRESS study (Early Use of Existing Preventive Strategies for Stroke), previously showing urgent assessment reduced 90-day stroke risk by 80%, we determined whether that early benefit was still evident long-term for stroke risk, disability, and costs. METHODS EXPRESS was a prospective population-based before (phase 1: April 2002-September 2004; n=310) versus after (phase 2: October 2004-March 2007; n=281) study of the effect of early assessment and treatment of transient ischemic attack/minor stroke on early recurrent stroke risk, with an external control. This report assesses the effect on 10-year recurrent stroke risk, functional outcomes, quality-of-life, and costs. RESULTS A reduction in stroke risk in phase 2 was still evident at 10 years (55/23.3% versus 82/31.6%; hazard ratio=0.68 [95% CI, 0.48-0.95]; P=0.024), as was the impact on risk of disabling or fatal stroke (17/7.7% versus 32/13.1%; hazard ratio=0.54 [0.30-0.97]; P=0.036). These effects were due to maintenance of the early reduction in stroke risk, with neither additional benefit nor rebound catch-up after 90 days (post-90 days hazard ratio=0.88 [0.65-1.44], P=0.88; and hazard ratio=0.83 [0.42-1.65], P=0.59, respectively). Disability-free life expectancy was 0.59 (0.03-1.15; P=0.043) years higher in patients in phase 2, as was quality-adjusted life expectancy (0.49 [0.03-0.95]; P=0.036). Overall, 10-year costs were nonsignificantly higher in patients attending the phase 2 clinic ($1022 [-3865-5907]; P=0.66). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds. CONCLUSIONS Urgent assessment and treatment of patients with transient ischemic attack or minor stroke resulted in a long-term reduction in recurrent strokes and improved outcomes, with little atrophy of the early benefit over time, representing good value for money even with a 10-year time horizon. Our results suggest that other effective acute treatments in transient ischemic attack/minor stroke in the short-term will also have the potential to have long-term benefit.
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Affiliation(s)
- Ramon Luengo-Fernandez
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Louise Silver
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Sergei Gutnikov
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Nicola C Beddows
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
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16
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Garg A, Maran I, Amin H, Vlieks K, Neuschatz K, Coppola A, Poskus K, Johnson J, Davis M, Minja F, Schindler J, Sansing LH, Malhotra A, Jasne AS, Sharma R. Expedited and Comprehensive Management of Low-Risk TIA Patients in the Emergency Department is Safe and Less Costly. J Stroke Cerebrovasc Dis 2021; 30:106016. [PMID: 34325273 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Transient ischemic attack (TIA) can be a warning sign of an impending stroke. The objective of our study is to assess the feasibility, safety, and cost savings of a comprehensive TIA protocol in the emergency room for low-risk TIA patients. MATERIALS AND METHODS This is a retrospective, single-center cohort study performed at an academic comprehensive stroke center. We implemented an emergency department-based TIA protocol pathway for low-risk TIA patients (defined as ABCD2 score < 4 and without significant vessel stenosis) who were able to undergo vascular imaging and a brain MRI in the emergency room. Patients were set up with rapid outpatient follow-up in our stroke clinic and scheduled for an outpatient echocardiogram, if indicated. We compared this cohort to TIA patients admitted prior to the implementation of the TIA protocol who would have qualified. Outcomes of interest included length of stay, hospital cost, radiographic and echocardiogram findings, recurrent neurovascular events within 30 days, and final diagnosis. RESULTS A total of 138 patients were assessed (65 patients in the pre-pathway cohort, 73 in the expedited, post-TIA pathway implementation cohort). Average time from MRI order to MRI end was 6.4 h compared to 2.3 h in the pre- and post-pathway cohorts, respectively (p < 0.0001). The average length of stay for the pre-pathway group was 28.8 h in the pre-pathway cohort compared to 7.7 h in the post-pathway cohort (p < 0.0001). There were no differences in neuroimaging or echocardiographic findings. There were no differences in the 30 days re-presentation for stroke or TIA or mortality between the two groups. The direct cost per TIA admission was $2,944.50 compared to $1,610.50 for TIA patients triaged through the pathway at our institution. CONCLUSIONS This study demonstrates the feasibility, safety, and cost-savings of a comprehensive, emergency department-based TIA protocol. Further study is needed to confirm overall benefit of an expedited approach to TIA patient management and guide clinical practice recommendations.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Ilavarasy Maran
- Department of Neurology, Trillium Health Partners, Missisauga, Canada
| | - Hardik Amin
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Kelsey Vlieks
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | | | | | | | | | | | - Frank Minja
- Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Ajay Malhotra
- Department of Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Adam S Jasne
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, 15 York St., LLCI 1003C, New Haven, New Haven, CT 06511, USA.
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17
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Liberman AL, Zhang H, Rostanski SK, Cheng NT, Esenwa CC, Haranhalli N, Singh P, Labovitz DL, Lipton RB, Prabhakaran S. Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department. J Am Heart Assoc 2021; 10:e019001. [PMID: 34056914 PMCID: PMC8477874 DOI: 10.1161/jaha.120.019001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Hui Zhang
- The Center for Health and the Social Sciences University of Chicago Chicago IL
| | - Sara K Rostanski
- Department of Neurology New York University Grossman School of Medicine New York NY
| | - Natalie T Cheng
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Charles C Esenwa
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Neil Haranhalli
- Department of Neurosurgery and Radiology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Puneet Singh
- Department of Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Daniel L Labovitz
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Richard B Lipton
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Shyam Prabhakaran
- Department of Neurology University of Chicago School of Medicine Chicago IL
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18
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Shapiro SD, Boehme AK, Chang BP, Miller EC, Willey J, Elkind MSV. Safety and Hospital Costs Averted Using a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Strokes: The RAVEN Clinic. Neurohospitalist 2020; 11:107-113. [PMID: 33791052 DOI: 10.1177/1941874420972236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Study Objective Patients presenting to emergency departments (ED) with transient ischemic attack and minor strokes (TIAMS) are often admitted for evaluation, though experience in other countries have suggested that an expedited outpatient care models may be a safe alternative. We hypothesized that a rapid access clinic for select TIAMS was feasible and would avert hospitalization costs. Methods This retrospective analysis included patients presenting to our institution's ED with TIAMS and NIHSS ≤5 in calendar year 2017. We referred low-risk patients with TIAMS to a Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic within 24 hours of ED discharge. We identified admitted patients who met RAVEN criteria at ED presentation. Rates of follow-up to the RAVEN clinic were recorded. Financial data collected included total hospital costs and time spent in the ED, as well hospital length of stay for admitted patients with low-risk TIAMS. Results In 2017, 149 patients were referred to RAVEN clinic and 50 patients were admitted. Of the RAVEN patients 99 (94%) appeared as scheduled. None had clinical changes between ED discharge and clinical evaluation. One patient required hospitalization at the RAVEN evaluation. When compared to RAVEN patients, admitted patients had significantly higher $7,719 (SD 354) total hospital costs and were hospitalized for 2 days on average. Overall, the RAVEN strategy averted approximately $764,000 in hospitalization costs and 208 hospital bed-days in accounting year 2017. Conclusions For select patients presenting with TIAMS without disabling deficits, a rapid outpatient evaluation may be feasible while averting significant total hospital costs and preserving inpatient hospital beds.
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Affiliation(s)
- Steven D Shapiro
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Amelia K Boehme
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Bernard P Chang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Joshua Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, USA
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19
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Lim A, Singhal S, Lavallee P, Amarenco P, Rothwell PM, Albers G, Sharma M, Brown R, Ranta A, Maddula M, Kleinig T, Dawson J, Elkind MSV, Guarino M, Coutts SB, Clissold B, Ma H, Phan T. An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2020; 29:105228. [PMID: 33066882 PMCID: PMC7434484 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.
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Affiliation(s)
- Andy Lim
- Department of Emergency Medicine, Monash Medical Centre, Melbourne, Australia; School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Shaloo Singhal
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Philippa Lavallee
- Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences. Level 6, West Wing, John Radcliffe Hospital, Oxford, United Kingdom
| | - Gregory Albers
- Department of Neurology and Stanford Stroke Center, Stanford Medical Center, Palo Alto, CA, USA
| | - Mukul Sharma
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Robert Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington
| | - Mohana Maddula
- Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Metropolitana (NeuroMet), Neurologia AOU S.Orsola, Malpighi, Bologna, Italy
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Benjamin Clissold
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia
| | - Thanh Phan
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology, Monash Medical Centre, Melbourne, Australia.
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20
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Poupore N, Strat D, Mackey T, Brown K, Snell A, Nathaniel TI. Thrombolytic therapy in ischemic stroke patients with a preceding transient ischemic attack in telestroke and non‐telestroke settings. ACTA ACUST UNITED AC 2020. [DOI: 10.1111/ncn3.12426] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Nicolas Poupore
- University of South Carolina School of Medicine Greenville Greenville SC USA
| | - Dan Strat
- University of South Carolina School of Medicine Greenville Greenville SC USA
| | - Tristan Mackey
- University of South Carolina School of Medicine Greenville Greenville SC USA
| | - Katherine Brown
- University of South Carolina School of Medicine Greenville Greenville SC USA
| | - Ashley Snell
- University of South Carolina School of Medicine Greenville Greenville SC USA
| | - Thomas I. Nathaniel
- University of South Carolina School of Medicine Greenville Greenville SC USA
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21
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Zhang Q, Li Y, Al-Turjman F, Zhou X, Yang X. Transient ischemic attack analysis through non-contact approaches. HUMAN-CENTRIC COMPUTING AND INFORMATION SCIENCES 2020. [DOI: 10.1186/s13673-020-00223-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
The transient ischemic attack (TIA) is a kind of sudden disease, which has the characteristics of short duration and high frequency. Since most patients can return to normal after the onset of the disease, it is often neglected. Medical research has proved that patients are prone to stroke in a relatively short time after the transient ischemic attacks. Therefore, it is extremely important to effectively monitor transient ischemic attack, especially for elderly people living alone. At present, video monitoring and wearing sensors are generally used to monitor transient ischemic attacks, but these methods have certain disadvantages. In order to more conveniently and accurately monitor transient ischemic attack in the indoor environment and improve risk management of stroke, this paper uses a microwave sensing platform working in C-Band (4.0 GHz–8.0 GHz) to monitor in a non-contact way. The platform first collects data, then preprocesses the data, and finally uses principal component analysis to reduce the dimension of the data. Two machine learning algorithms support vector machine (SVM) and random forest (RF) are used to establish prediction models respectively. The experimental results show that the accuracy of SVM and RF approaches are 97.3% and 98.7%, respectively; indicating that the scheme described in this paper is feasible and reliable.
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22
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Chang BP, Cornelius T, Willey J, Edmondson D, Elkind MS, Kronish IM. Are patients afraid to go home? Disposition preferences after transient ischaemic attack and minor stroke. Emerg Med J 2020; 37:486-488. [PMID: 31992569 DOI: 10.1136/emermed-2019-209154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent evidence suggests clinical equipoise for managing transient ischaemic attack and minor stroke (TIAMS) either via discharge from the emergency department (ED) with rapid outpatient follow-up or inpatient admission. Understanding patient preferences may guide decision-making around disposition after TIAMS that can lead to higher patient satisfaction and adherence. Psychological distress, particularly a sense of vulnerability (eg, 'threat perception') is associated with adverse psychological outcomes following TIAMS and may influence patient disposition preference. We hypothesised patients with higher threat perceptions in the ED would prefer inpatient admission versus early discharge with rapid outpatient follow-up. METHODS This was a planned secondary analysis of a prospective observational cohort study of ED patients with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported disposition preferences and completed a validated scale of threat perception while in the ED (score range: 1-4). RESULTS 147 TIAMS patients were evaluated (mean age: 59.7±15.4, 45.6% female, 39.5% Hispanic, median NIHSS=1, IQR: 0, 3). A majority of patients (98, 66.7%) preferred inpatient admission compared with discharge from the ED. Overall threat scores were median 1.0 (IQR: 0.43, 1.68). Those preferring admission had similar threat scores compared with those who preferred early disposition (median: 1.00, IQR: 0.43, 1.57) versus 1.00, (IQR: 0.49, 1.68); p=0.40). In a model adjusted for demographic characteristics, threat perceptions remained unassociated with disposition preference. CONCLUSION Overall, two-thirds of TIAMS patients preferred inpatient admission over discharge. Disposition preference was not associated with higher threat perception in the ED. Further research examining potential drivers of patient disposition preferences may inform patient discussions and optimise patient satisfaction.
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Affiliation(s)
- Bernard P Chang
- Emergency Medicine, Columbia University Medical Center, New York, New York, USA
| | - Talea Cornelius
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, New York, USA
| | - Joshua Willey
- Neurology, Columbia University, New York, New York, USA
| | - Donald Edmondson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, New York, USA
| | | | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, New York, USA
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Madsen TE, Wira CR. The Future of Minor Stroke and Transient Ischemic Attack: The RAVEN Approach Is Promising but Not Ready for Prime Time. Ann Emerg Med 2019; 74:572-574. [DOI: 10.1016/j.annemergmed.2019.08.458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Indexed: 11/27/2022]
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