Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected acute minor stroke or transient ischemic attack (TIA) (n=1076). Intervention: Specialized neurovascular outpatient clinic setup with risk-based triage and subsequent admission of high-risk patients vs. Historic (same hospital) and contemporary (another comparable university hospital) matched, hospitalized stroke unit controls. Primary outcome: 30-day hospital readmission rate (in matched stroke cohort vs historic stroke cohort, one of four nonprioritized primary outcomes alongside length of stay, care quality, and mortality) (adjusted HR 0.23, 95% CI 0.09-0.59).

Sidsel Hastrup; Søren Paaske Johnsen; Martin Jensen; Paul von Weitzel‐Mudersbach; Claus Z. Simonsen; Niels Hjort; Anette Torvin Møller; Thomas Harbo; Marika Poulsen; Helle K. Iversen; Dorte Damgaard; Grethe Andersen

doi:10.1212/wnl.0000000000011453

January 20, 2021NeurologyOpen Access

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke

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Key result

Outpatient neurovascular clinic linked to ~77% lower 30-day readmissions vs stroke unit admission for minor stroke/TIA.

adjusted HR 0.23
95% CI 0.09-0.59
n=1,076

Figures

Why the study?

The study was conducted to evaluate the effects of an outpatient clinic setup for minor stroke or TIA using subsequent admission of patients at high risk of recurrent stroke.

Does a specialized acute neurovascular outpatient clinic setup with selective admission of high-risk patients reduce length of hospital stay and readmissions while maintaining safety and care quality compared to routine stroke unit hospitalization in patients with minor stroke or TIA?

Key Points

To evaluate the safety, length of stay, readmissions, and quality of care associated with a specialized outpatient clinic setup that selectively admits patients with minor stroke or TIA at high risk of recurrence.
Prospective cohort study analyzing 1,076 consecutive patients with suspected minor stroke or TIA at Aarhus University Hospital, Denmark, between September 2013 and August 2014.
Following diagnostic workup, patients were stratified into low- or high-risk categories for recurrent stroke within 7 days using clinical risk factors and imaging.
Patients with stroke were matched and compared to historic (n = 191) and contemporary (n = 194) hospitalized controls; patients with TIA were compared to matched contemporary hospitalized controls.
In the matched historic comparison (n = 191 per group), stroke patients managed via the outpatient model had a shorter acute stay (median 1 vs 3 days; adjusted length of stay ratio 0.49, 95% CI 0.33–0.71) and lower 30-day readmission (3.2% vs 11.6%; adjusted HR 0.23, 95% CI 0.09–0.59).
Process quality of care ('all-or-none' of 10 measures) was higher in stroke outpatients than historic controls (84.3% vs 64.9%; RR 1.30, 95% CI 1.15–1.47), with similar findings observed against contemporary controls.
Among 170 low-risk stroke and TIA patients discharged directly from the clinic without admission, only 1 patient (0.6%) experienced a recurrent stroke within 7 days.

Study Design

Type

Cohort (n=1,076)

Multicenter

Yes

Structured PICO

Does a specialized acute neurovascular outpatient clinic setup with selective admission of high-risk patients reduce length of hospital stay and readmissions while maintaining safety and care quality compared to routine stroke unit hospitalization in patients with minor stroke or TIA?

P

Population

1,076 consecutive self-reliant adults (approximate age 66-67 years in matched cohorts) with suspected acute minor stroke or TIA evaluated at a Danish specialized neurovascular outpatient clinic and followed for up to 365 days.

E

Exposure

Same-day evaluation and treatment in a specialized neurovascular doctor-driven acute outpatient clinic (open 8 am–6 pm, 7 days/week; including standard brain MRI, carotid/intracranial vascular imaging, blood samples, ECG, and rehabilitation evaluation), followed by systematic risk assessment (using ABCD2/NIHSS, imaging, and cardioembolic risk factors) to discharge low-risk patients directly home with 7-day phone follow-up and admit high-risk patients to the stroke ward.

C

Comparator

Direct hospitalization in an acute stroke unit, assessed via 1:1 matched historic controls from the same hospital (May 2011 to April 2012, n=191 for stroke) and 1:1 matched contemporary controls from a comparable university hospital without an acute outpatient clinic (Glostrup Hospital, Capital Region, n=194 for stroke and matched cohort for TIA). Matching criteria: age group, sex, Scandinavian Stroke Scale severity group, thrombolysis treatment/door-to-needle time, and diagnosis subtype.

O

Outcome

Nonprioritized primary outcomes over up to 365 days follow-up: length of acute and total (including in-hospital rehabilitation) hospital stay, all-cause bed days within the first year, hospital readmissions after discharge (0–30 and 31–365 days), mortality (0–30 and 0–365 days), and quality of care (10 process-performance measures for stroke, 4 for TIA, evaluated as 'all or none' and 'opportunity-based' composite scores).hard clinical

Main Result

Hazard Ratio: 0.23 (95% CI 0.09–0.59)

Absolute Event Rate: 3.2% vs 11.6%

A hybrid neurovascular outpatient clinic that triages minor stroke and TIA patients for selective inpatient admission safely reduces hospital length of stay and 30-day readmissions while improving care quality compared to routine stroke unit admission.

Limitations

Nonrandomized study design carries a risk of residual confounding
Comparison with historic controls may be subject to confounding by calendar time-related trends of improvement in stroke care
Historic controls for patients with TIA were lacking because TIA registration in the Danish Stroke Registry was not implemented until mid-2013
Contemporary control cohort from another hospital is vulnerable to local institutional differences
Unable to calculate a reliable rate of early recurrent stroke in hospitalized patients or reference cohorts due to lack of 7-day telephone follow-up in those groups
Nonrandomized observational design carries a risk of confounding affecting length of stay, readmissions, and mortality
Comparison with historic controls is subject to confounding by underlying calendar time-related trends in stroke care
Lack of historic controls for TIA patients because TIA registration in the Danish Stroke Registry was not implemented until mid-2013
Comparison with contemporary controls from another hospital is vulnerable to local inter-hospital differences
Inability to calculate reliable early recurrent stroke rates in hospitalized study patients or reference cohorts due to lack of registration in the Danish Stroke Registry and absence of 7-day telephone follow-up in hospitalized groups

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Answers are grounded in this paper and cite their sources.

Implication

Supports selective outpatient triage for low-risk minor stroke/TIA; leaves open need for randomized confirmation before practice change.

Abstract

OBJECTIVE: To evaluate the effects of an outpatient clinic setup for minor stroke/TIA using subsequent admission of patients at high risk of recurrent stroke. METHODS: We performed a cohort study of all patients with suspected minor stroke/TIA seen in an outpatient clinic at Aarhus University Hospital, Denmark, between September 2013 and August 2014. Patients with stroke were compared to historic (same hospital) and contemporary (another comparable hospital) matched, hospitalized controls on nonprioritized outcomes: length of stay, readmissions, care quality (10 process-performance measures), and mortality. Patients with TIA were compared to contemporary matched, hospitalized controls. Following complete diagnostic workup, patients with stroke/TIA were classified into low/high risk of recurrent stroke ≤7 days. RESULTS: We analyzed 1,076 consecutive patients, of whom 253 (23.5%) were subsequently admitted to the stroke ward. Stroke/TIA was diagnosed in 215/171 patients, respectively. Fifty-six percent (121/215) of the patients with stroke were subsequently admitted to the stroke ward. Comparison with the historic stroke cohort (n = 191) showed a shorter acute hospital stay for the strokes (median 1 vs 3 days; adjusted length of stay ratio 0.49; 95% confidence interval 0.33-0.71). Thirty-day readmission rate was 3.2% vs 11.6% (adjusted hazard ratio 0.23 [0.09-0.59]), and care quality was higher, with a risk ratio of 1.30 (1.15-1.47). The comparison of stroke and TIAs to contemporary controls showed similar results. Only one patient in the low risk category and not admitted experienced stroke within 7 days (0.6%). CONCLUSIONS: An outpatient clinic setup for patients with minor stroke/TIA yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that a neurovascular specialist-driven outpatient clinic for patients with minor stroke/TIA with the ability of subsequent admission is safe and yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

Discussion

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Cite This Study

Hastrup et al. (2021) conducted a cohort in Suspected acute minor stroke or transient ischemic attack (TIA) (n=1,076). Specialized neurovascular outpatient clinic setup with risk-based triage and subsequent admission of high-risk patients vs. Historic (same hospital) and contemporary (another comparable university hospital) matched, hospitalized stroke unit controls was evaluated on 30-day hospital readmission rate (in matched stroke cohort vs historic stroke cohort, one of four nonprioritized primary outcomes alongside length of stay, care quality, and mortality) (adjusted HR 0.23, 95% CI 0.09-0.59). A specialized neurovascular outpatient clinic for minor stroke/TIA reduced 30-day readmissions and acute hospital stay (median 1 vs 3 days) vs stroke unit admission.

synapsesocial.com/papers/6a7c5c1989223840d9085a38 https://doi.org/10.1212/wnl.0000000000011453

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Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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