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Turner GM, McMullan C, Atkins L, Foy R, Mant J, Calvert M. TIA and minor stroke: a qualitative study of long-term impact and experiences of follow-up care. BMC FAMILY PRACTICE 2019; 20:176. [PMID: 31847828 PMCID: PMC6918619 DOI: 10.1186/s12875-019-1057-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/21/2019] [Indexed: 12/15/2022]
Abstract
Background Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided. We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support. Methods This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care. Data was analysed using framework analysis. Results A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems. Conclusion HCPs could better communicate information about TIA/minor stroke diagnosis and secondary stroke prevention using lay language, and improve their identification of and response to important residual impairments affecting patients.
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Affiliation(s)
- Grace M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Christel McMullan
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Lou Atkins
- Centre for Behaviour Change, University College London, London, WC1E 6BT, UK
| | - Robbie Foy
- Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Melanie Calvert
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, B15 2TT, UK
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Edwards D, Turner GM, Virdee SK, Mant J. The role of the GP in managing suspected transient ischaemic attack: a qualitative study. BMC FAMILY PRACTICE 2019; 20:67. [PMID: 31113364 PMCID: PMC6530060 DOI: 10.1186/s12875-019-0963-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND National guidelines recommend patients with suspected transient ischaemic attack (TIA) should be seen by a specialist within 24 h. However, people with suspected TIA often present to non-specialised services, particularly primary care. Therefore, general practitioners (GPs) have a crucial role in recognition and urgent referral of people with suspected TIA. This study aims to explore the role of GPs in the initial management of suspected TIA in the United Kingdom (UK). METHODS One-to-one, semi-structured interviews with GPs, TIA clinic staff and patients with suspected TIA from two sites in the UK: Cambridge and Birmingham. Thematic analysis was undertaken to explore views on the role of the GP in managing suspected TIA. Thirty semi-structured interviews were conducted with stroke patients (n = 12), GPs (n = 9) and TIA clinic hospital staff (n = 9) from two hospitals and nine GP practices in surrounding areas. RESULTS Three overarching themes were identified: (1) multiple management pathways for suspected TIA; (2) uncertainty regarding suspected TIA as an emergency or routine situation; and (3) influences on the urgency of GP management. CONCLUSIONS Guidelines on the primary care management of TIA describe only a small proportion of the factors which influence GP management and referral of suspected TIA. Efforts to improve treatment, appropriate referral and patient experience should use a real rather than idealised model of the GP role in managing suspected TIA.
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Affiliation(s)
- Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Grace M Turner
- Institute for Applied Health Research, University of Birmingham, Birmingham, Edgbaston, B15 2TT, UK.
| | - Satnam K Virdee
- Institute for Applied Health Research, University of Birmingham, Birmingham, Edgbaston, B15 2TT, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
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Leontyev S, Davierwala PM, Semenov M, von Aspern K, Krog G, Noack T, Misfeld M, Borger MA. Antegrade selective cerebral perfusion reduced in-hospital mortality and permanent focal neurological deficit in patients with elective aortic arch surgery†. Eur J Cardiothorac Surg 2019; 56:1001-1008. [DOI: 10.1093/ejcts/ezz091] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/20/2019] [Accepted: 02/23/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractOBJECTIVESWe retrospectively evaluated the outcome after elective aortic arch surgery with circulatory arrest to determine the impact of different brain protection strategies on neurological outcome and early and late survival.METHODSA total of 925 patients were included. The patients were assigned to 2 groups based on the type of cerebral protection strategy used during circulatory arrest [hypothermic circulatory arrest (HCA) n = 224; antegrade selective cerebral perfusion (ASCP) n = 701]. The propensity score matching (1:1; 210 vs 210 patients) approach was used to minimize selection bias and to obtain comparable groups.RESULTSThe overall in-hospital mortality and permanent focal neurological deficit rates were 5.6% (n = 52) and 5.4% (n = 50) and were significantly lower in patients who received ASCP (4.4% and 3.4%, respectively) as compared to those who underwent HCA (9.4% and 11.6%, respectively) (P = 0.005 and P < 0.001). The propensity-matched analysis showed significantly lower rates of in-hospital mortality [3.8% vs 9.5% (HCA)] and permanent focal neurological deficit in ASCP group [2.9% vs 11.9% (HCA)]. Multivariable logistic regression analysis revealed left ventricular ejection fraction <30%, age >70 years, coronary artery disease, circulatory arrest time >40 min and mitral valve disease as independent predictors of in-hospital mortality. The use of ASCP was protective for early survival. Cox regression analysis revealed that long-term mortality was independently predicted by age, left ventricular ejection fraction <30%, total arch replacement, prior cardiac surgery, PVD, chronic obstructive pulmonary disease and previous stroke, whereas ASCP was protective for late survival.CONCLUSIONSElective aortic arch surgery is associated with acceptable early and late outcomes. The ASCP is associated with a significant reduction in-hospital mortality and occurrence of permanent neurological deficits.
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Affiliation(s)
- Sergey Leontyev
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Mikhail Semenov
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Gunter Krog
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Levi CR, Lasserson D, Quain D, Valderas J, Dewey HM, Alan Barber P, Spratt N, Cadilhac DA, Feigin V, Zareie H, Garcia Esperon C, Davey A, Najib N, Magin P. The International comparison of Systems of care and patient outcomes In minor Stroke and Tia (InSIST) study: A community-based cohort study. Int J Stroke 2019; 14:186-190. [PMID: 30608031 DOI: 10.1177/1747493018799983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
RATIONALE Rapid response by health-care systems for transient ischemic attack and minor stroke (TIA/mS) is recommended to maximize the impact of secondary prevention strategies. The applicability of this evidence to Australian non-hospital-based TIA/mS management is uncertain. AIMS Within an Australian community setting we seek to document processes of care, establish determinants of access to care, establish attack rates and determinants of recurrent vascular events and other clinical outcomes, establish the performance of ABC2-risk stratification, and compare the processes of care and outcomes to those in the UK and New Zealand for TIA/mS. SAMPLE SIZE ESTIMATES Recruiting practices containing approximately 51 full-time-equivalent general practitioners to recruit 100 TIA/mS per year over a four-year study period will provide sufficient power for each of our outcomes. METHODS AND DESIGN An inception cohort study of patients with possible TIA/mS recruited from 16 general practices in the Newcastle-Hunter Valley-Manning Valley region of Australia. Potential TIA/mS will be ascertained by multiple overlapping methods at general practices, after-hours collaborative, and hospital in-patient and outpatient services. Participants' index and subsequent clinical events will be adjudicated as TIA/mS or mimics by an expert panel. STUDY OUTCOMES Process outcomes-whether the patient was referred for secondary care; time from event to first patient presentation to a health professional; time from event to specialist acute-access clinic appointment; time from event to brain and vascular imaging and relevant prescriptions. Clinical outcomes-recurrent stroke and major vascular events; and health-related quality of life. DISCUSSION Community management of TIA/mS will be informed by this study.
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Affiliation(s)
- Christopher R Levi
- 1 John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia.,2 Department of Neurology, The University of Newcastle, Newcastle, Australia.,3 The Ingham Institute, SPHERE, Sydney, Australia
| | - Daniel Lasserson
- 4 Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,5 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Debbie Quain
- 6 Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | - Jose Valderas
- 7 Health Services & Policy Research, Academic Collaboration for Primary Care (APEx), NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, Exeter, UK
| | - Helen M Dewey
- 8 Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Australia
| | - P Alan Barber
- 9 Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Neil Spratt
- 1 John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia.,2 Department of Neurology, The University of Newcastle, Newcastle, Australia
| | - Dominique A Cadilhac
- 10 Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Parkville, Australia.,11 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Valery Feigin
- 12 National Institute for Stroke & Applied Neurosciences, AUT University, Auckland, New Zealand
| | - Hossein Zareie
- 6 Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | | | - Andrew Davey
- 13 Discipline of General Practice, University of Newcastle, Newcastle, Australia
| | - Nashwa Najib
- 13 Discipline of General Practice, University of Newcastle, Newcastle, Australia
| | - Parker Magin
- 13 Discipline of General Practice, University of Newcastle, Newcastle, Australia
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Ziebland S, Locock L, Fitzpatrick R, Stokes T, Robert G, O’Flynn N, Bennert K, Ryan S, Thomas V, Martin A. Informing the development of NICE (National Institute for Health and Care Excellence) quality standards through secondary analysis of qualitative narrative interviews on patients’ experiences. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02450] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BackgroundWe set out to explore if, and how, an archive of qualitative, narrative interviews covering over 60 health issues could be used to inform the development of National Institute for Health and Care Excellence (NICE) quality standards. We also sought to identify which aspects of health care are important to people facing different health conditions and to test a set of ‘core components’ in focus groups with people who tend to be less well represented in interview research studies.Objectives(1) To conduct qualitative secondary analysis (of collections of narrative interviews) to identify common, core components of patients’ experiences of the NHS. (2) To test these candidate components with (i) further purposive sampling of the interview collections and (ii) a series of focus groups with users. (3) To embed the project alongside the development of NICE clinical guidelines and quality standards. (4) To inform the development of measurement tools on patients’ experiences. (5) To develop and share resources and skills for secondary analysis of qualitative health research.Methods and data sourcesWe used qualitative methods including qualitative secondary analysis, interviews with team members and focus groups. We also ran a workshop on secondary analysis practice and a dissemination seminar. The secondary analysis used narrative interviews from the archive held by the Health Experiences Research Group in Oxford. These interviews have been collected over a 12-year period, number over 3500 and are copyrighted to the University of Oxford for research publications and broadcasting. Other data were digital recordings of interviews and observations at meetings. We prepared reports intended to contribute to NICE clinical guidelines and quality standards development.ResultsWe identified eight consistently important aspects of care: involving the patient in decisions; a friendly and caring attitude; an understanding of how life is affected; seeing the same health professional; guiding through difficult conversations; taking time to explain; pointing towards further support; and efficiently sharing health information across services. Expectations varied but we found few differences in what is valued, even when we tested the reach of these ideas with groups who rarely take part in mainstream health research. The asthma report for NICE highlighted several issues, but only the importance of proper inhaler training contributed to a quality statement. Several barriers were identified to using (unpublished) tailor-made analyses in NICE product development.ConclusionsWe compared the perspectives about what is most valued in health care between people with different health conditions. They were in agreement, even though their experiences of health-care relationships varied enormously. With regard to the NICE clinical guideline and quality standard development process, the usual source of evidence is published qualitative or quantitative research. Unpublished secondary analysis of qualitative data did not fit the usual criteria for evidence. We suggest that targeted secondary analysis of qualitative data has more potential when the qualitative literature is sparse, unclear or contradictory. Further work might include further testing of the identified core components in other patient groups and health conditions, and collaboration with NICE technical teams to establish whether or not it is possible to identify areas of patient experience research where targeted secondary analyses have potential to add to a qualitative literature synthesis.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tim Stokes
- National Institute for Health and Care Excellence, Manchester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Glenn Robert
- National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
| | | | - Kristina Bennert
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sara Ryan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Victoria Thomas
- Patient and Public Involvement Programme, National Institute for Health and Care Excellence, London, UK
| | - Angela Martin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Intérêt des textos (SMS) pour le diagnostic de troubles du langage au cours des accidents vasculaires cérébraux. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mc Sharry J, Baxter A, Wallace LM, Kenton A, Turner A, French DP. Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study. PLoS One 2014; 9:e104434. [PMID: 25137185 PMCID: PMC4138063 DOI: 10.1371/journal.pone.0104434] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 07/14/2014] [Indexed: 12/29/2022] Open
Abstract
Background Prompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay. Methods Twenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category. Results Delay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions. Conclusions This study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.
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Affiliation(s)
- Jennifer Mc Sharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland
- * E-mail:
| | - Alison Baxter
- Applied Research Centre in Health & Lifestyle Interventions, Coventry University, Coventry, United Kingdom
| | - Louise M. Wallace
- Applied Research Centre in Health & Lifestyle Interventions, Coventry University, Coventry, United Kingdom
| | - Anthony Kenton
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, United Kingdom
| | - Andrew Turner
- Applied Research Centre in Health & Lifestyle Interventions, Coventry University, Coventry, United Kingdom
| | - David P. French
- Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
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