ED Referral Dramatically Reduces Delays of Initial Evaluation in a French TIA Clinic

Abstract

Background: The risk of recurrent brain infarction (BI) is high within the first hours after a transient ischemic attack (TIA). Emergent, specialized, and tailored patient management in a TIA program reduces the risk of recurrent BI after TIA by 80%. New antithrombotic strategies have been successfully tested within 12 h after TIA onset. We aim to investigate the factors associated with a delay of more than 12 h from TIA onset to evaluation in our TIA clinic.Methods: In consecutive patients evaluated in our TIA clinic from 01/2012 to 11/2013, we prospectively collected delays from onset to arrival, baseline characteristics, discharge diagnosis and recurrent BI at 1 week. Referring pathways were dichotomized between office-based physicians (OBP) and emergency departments (ED). Univariate and multivariate logistic regression were performed.Results: 354 patients were evaluated. Mean (+/– SD) age was 61 years (+/−18). Median (IQR) ABCD2 score was 3 (2–4). Median (IQR) delay from onset to evaluation was 8 h (4–48). Overall, 185 (52%) were referred by OBP vs. 169 (48%) by ED. Evaluation was initiated within 12 h among 201 (57%) patients. After logistic regression, OBP referral was by comparison with ED the only independent factor associated with an evaluation delay >12 h (OR 5.7, 95% CI: 3.5–9.3, p < 0.0001).Conclusion: Our results suggest that preliminary assessment by OBP may increase the delay to initiate the emergent evaluation of TIA patients. Promoting direct admission to TIA clinics through ED may be an efficient alternative for high risk TIAs.

Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack

“…9 , 29 , 30 , 31 , 32 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 Among the inpatients (33 cohorts; 130 139 patients; mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 21 cohorts (125 719 patients) received care in medical-surgical units (A. Mowla, MD, unpublished data, 2020), 9 , 15 , 27 , 32 , 38 , 39 , 40 , 41 , 51 , 52 , 53 , 55 , 58 , 59 , 64 , 65 , 79 , 81 , 83 , 84 5 cohorts (2487 patients) in stroke units, 49 , 63 , 79 , 80 , 92 and 7 cohorts (1933 patients) in observation units. 48 , 65 , 66 , 82 , 83 , 84 , 95 In 16 cohorts (3605 patients; mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), the acute care was offered at the ED (A. Mowla, MD, unpublished data, 2020). 15 , 33 , 34 , 35 , 36 , 37 , 40 , 61 , 67...…”

“…Review of the reference lists, citation tracking, and communication with authors led to inclusion of four additional studies. A total of 71 studies were included (A. Mowla, MD, unpublished data, 2020) …”

“…In 15 cohorts (5636 patients; mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men) acute care was delivered in TIA clinics (A. Mowla, MD, unpublished data, 2020) . Among the inpatients (33 cohorts; 130 139 patients; mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 21 cohorts (125 719 patients) received care in medical-surgical units (A. Mowla, MD, unpublished data, 2020), 5 cohorts (2487 patients) in stroke units, and 7 cohorts (1933 patients) in observation units . In 16 cohorts (3605 patients; mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), the acute care was offered at the ED (A. Mowla, MD, unpublished data, 2020) .…”

“…eTable 7 in the Supplement summarizes the results of the risk of bias assessment according to ROBINS-E. Among the 63 cohorts with specified settings (ie, TIA clinic, inpatient, and ED) 59 cohorts (90.6%) had low risk of bias, and 4 cohorts (9.4%) had a moderate overall risk of bias …”

“…The men), 21 cohorts (125 719 patients) received care in medical-surgical units (A. Mowla, MD, unpublished data, 2020), 9,15,27,32,[38][39][40][41][51][52][53]55,58,59,64,65,79,81,83,84 5 cohorts (2487 patients) in stroke units, 49,63,79,80,92 and 7 cohorts (1933 patients) in observation units. 48,65,66,[82][83][84]95 In 16 cohorts (3605 patients; mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), the acute care was offered at the ED (A. Mowla, MD, unpublished data, 2020). 15,[33][34][35][36][37]40,61,67,68,81,85,87,93 The setting of care was not fully described or the study included the patients who received treatment in various care settings and multiple centers in 37 cohorts (87 303…”