Patients who had complete same-day workup in an outpatient clinic for suspected minor stroke or transient ischemic attack (TIA) had improved admissions and quality measures compared with those admitted directly to the stroke unit, a Danish cohort study found.
“This study provides Class III evidence that a neurovascular specialist driven outpatient clinic for minor stroke/TIA patients with the ability of subsequent admission is safe and yields shorter acute hospital stay, lower readmissions rates, and better quality than hospitalization in stroke units,” wrote Sidsel Hastrup, MD, PhD, of Aarhus University Hospital in Denmark, and co-authors, in Neurology. “The triage appears safe with a low rate of recurrent vascular events within the first week after returning home.”
“These findings suggest that primary outpatient management with only selective hospital admission may in fact be better than universal hospital admission,” wrote Annemarei Ranta, MD, PhD, of the University of Otago in New Zealand, and Rachael Hunter, MSc, of University College London in England, in an accompanying editorial.
The Aarhus University healthcare system admits all suspected stroke or TIA patients directly to the hospital stroke unit before 8 a.m. or after 6 p.m. each day. Between 8 and 6, suspected minor stroke or TIA patients designated as “high risk” are admitted from the clinic.
Researchers compared patients with suspected minor stroke or TIA seen first in the outpatient clinic to matched hospitalized controls. Those with minor stroke were compared with two groups: patients admitted at the researcher’s institution before the clinic’s existence (historical controls), and patients admitted to a regional hospital with no outpatient stroke clinic (contemporary controls). Those with TIA were compared only with patients at a regional hospital (contemporary controls). Disposition depended on same-day clinic findings and whether the patient was judged high or low risk for re-stroke in ≤7 days.
Of 1,076 outpatients with suspected stroke or TIA, 47.4% (n=510) had a neurovascular diagnosis (215 stroke, 171 TIA, and 124 another neurovascular diagnosis). Discharge from clinic to home occurred in about 44% of patients diagnosed with minor stroke and 71% of patients diagnosed with TIA. Among all clinic patients with suspected TIA or stroke, 23.5% were admitted after outpatient evaluation.
Compared with historical controls, median acute hospital stay for minor stroke was shorter for patients seen at the clinic first (median 1 vs 3 days; adjusted length-of-stay ratio 0.49, 95% CI 0.33-0.71). Readmission rate at 30 days was 3.2% for minor stroke patients seen at the clinic first versus 11.6% for historical controls (HR 0.23, 95% CI 0.09-0.59). Care quality was higher with a risk ratio of 1.30, 95% CI 1.15-1.47. Mortality rates at day 30 and day 365 were comparable between the two groups, at 0.0 versus 0.5% and 2.6% versus 5.2%, respectively.
Comparisons of minor stroke and TIA patients seen at the clinic to contemporary controls showed similar results. One patient with minor stroke in the “low-risk” category not admitted to the hospital experienced a stroke within 7 days (0.6%).
The study included outpatients with suspected stroke or TIA who presented to the clinic between September 2013 and August 2014. Patients had a mean age of about 66, and median time from onset of symptoms to evaluation was 1 day for stroke and 0 days for TIA.
Historical minor stroke controls were hospitalized between May 2011 and April 2012; contemporary controls were hospitalized at a comparable institution from 2013 to 2014. Danish registries provided information on hospitalizations, readmissions, and mortality.
Outpatient workup included MRI, vascular imaging as indicated (carotid ultrasound and CT or MRI angiography), blood tests, EKG, and history and physical examination. Cardiology referral for echocardiography was done on the day of evaluation, as were evaluations by physical and occupational therapy. Patients presenting with an indication for thrombolysis or thrombectomy were transferred to stroke unit care.
Risk for recurrent stroke within 7 days was assessed with vascular and stroke risk and severity scores, imaging results, and cardiovascular factors. Clinic patients who were sent home had no acute ischemia on MRI and low stroke severity scores, with carotid stenosis of less than 50%, no symptomatic stenosis seen or suspected of intracranial vessels, no major cardio-embolic risk factors, and no other indication for admission.
Those presenting with suspected stroke or TIA with no cerebrovascular diagnosis and major neurologic disease (e.g., tumor) were admitted to general neurology care at the hospital. Other dispositions were determined by clinical need, such as admission to another department or followup with outpatient primary care.
The editorial writers pointed out that the study provided evidence to support implementation of “… best practice care in outpatient clinics … A 7-day follow-up by telephone offered to half of the clinic cohort, not standardly used in the hospitalized cohorts, may also have prevented readmissions.”
The most common other neurovascular diagnoses from the clinic population besides stroke and TIA were amaurosis fugax (n=65), recrudescence of prior stroke (n=35), and subdural hemorrhage (n=6). Other diagnoses included abnormalities of skin sensation (n=112), migraine (n=62), dizziness (n=57), syncope/collapse (n=21), peripheral vestibular function (n=12), and infections (n=9).
Limitations include risk of confounding. Data sources lacked 3-month stroke recurrence rates, limiting comparison to other studies. In addition, “the proposed model relies on rapid availability of outpatient services potentially unachievable in many settings including same-day therapist assessment and Holter monitors,” the editorialists noted.
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Patients who had complete same-day workup in an outpatient clinic for suspected minor stroke or transient ischemic attack (TIA) had improved admissions and quality measures compared with those admitted directly to the stroke unit, a Danish cohort study found.
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The study provides Class III evidence that a neurovascular specialist-led outpatient clinic for minor stroke/TIA patients with the ability of subsequent hospital admission is safe and yields shorter acute hospital stay, lower readmissions rates, and better quality than admitting minor stroke and TIA patients directly to stroke units, the researchers said.
Paul Smyth, MD, Contributing Writer, BreakingMED™
This study was supported by the University of Aarhus, the Lundbeck Foundation, and the Laerdal Foundation.
Hastrup received a research grant from the University of Aarhus and the Lundbeck Foundation.
The editorialists reported no disclosures.
Cat ID: 38
Topic ID: 82,38,730,745,38,192,925
