Top

Published in:

01-09-2019 | Original Research

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Authors: Barbara J. Homoya, RN, MSN, Teresa M. Damush, PhD, Jason J. Sico, MD, MHS, Edward J. Miech, EdD, Gregory W. Arling, PhD, Laura J. Myers, PhD, Jared B. Ferguson, BS, Michael S. Phipps, MD, Eric M. Cheng, MD, MS, Dawn M. Bravata, MD

Published in: Journal of General Internal Medicine | Issue 9/2019

Abstract

Background

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably.

Objectives

We sought to identify factors associated with the decision to admit patents with TIA.

Design

We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review.

Participants

We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011.

Approach

For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD² scores (a tool to classify stroke risk after TIA).

Key Results

Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD² score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD² scores and related guidelines in admission decision-making.

Conclusions

Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–72. https://doi.org/10.1016/s1474-4422(07)70274-0.CrossRefPubMed

Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med. 2007;167(22):2417–22. https://doi.org/10.1001/archinte.167.22.2417.CrossRefPubMed

Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369(1):11–9. https://doi.org/10.1056/NEJMoa1215340.CrossRefPubMed

Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284(22):2901–6.CrossRefPubMed

Kelly AG, Rothwell PM. Evaluating patients with TIA: to hospitalize or not to hospitalize?. Neurology. 2011;77(24):2078–9. https://doi.org/10.1212/WNL.0b013e31824004fe.CrossRefPubMed

Johnston SC, Albers GW, Gorelick PB, Cumbler E, Klingman J, Ross MA, Briggs M, Carlton J, Sloan EP, Vaince U. National Stroke Association recommendations for systems of care for transient ischemic attack. Ann Neurol. 2011;69(5):872–7. https://doi.org/10.1002/ana.22332.CrossRefPubMed

Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009;40(6):2276–93. https://doi.org/10.1161/strokeaha.108.192218.CrossRefPubMed

Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, Phipps MS, Zillich AJ, Yu Z, Reeves M, Williams LS, Johanning J, Chaturvedi S, Baye F, Ofner S, Austin C, Ferguson J, Graham GD, Rhude R, Kessler CS, Higgins DS Jr, Cheng E. Quality of care for veterans with transient ischemic attack and minor stroke. JAMA Neurol. 2018;75(4):419–27. https://doi.org/10.1001/jamaneurol.2017.4648.CrossRefPubMedPubMedCentral

Scholte op Reimer WJ, Dippel DW, Franke CL, van Oostenbrugge RJ, de Jong G, Hoeks S, Simoons ML. Quality of hospital and outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands. Stroke. 2006;37(7):1844–9. https://doi.org/10.1161/01.STR.0000226463.17988.a3.CrossRefPubMed

10.

Kehdi EE, Cordato DJ, Thomas PR, Beran RG, Cappelen-Smith C, Griffith NC, Hanna IY, McDougall AJ, Worthington JM, Hodgkinson SJ. Outcomes of patients with transient ischaemic attack after hospital admission or discharge from the emergency department. Med J Aust. 2008;189(1):9–12.CrossRefPubMed

11.

Kapral MK, Hall R, Fang J, Austin PC, Silver FL, Gladstone DJ, Casaubon LK, Stamplecoski M, Tu JV. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582–9. https://doi.org/10.1212/wnl.0000000000002614.CrossRefPubMedPubMedCentral

12.

Ramirez L, Kim-Tenser MA, Sanossian N, Cen S, Wen G, He S, Mack WJ, Towfighi A. Trends in transient ischemic attack hospitalizations in the United States. J Am Heart Assoc. 2016;5(9). https://doi.org/10.1161/jaha.116.004026.

13.

Nguyen-Huynh MN, Johnston SC. Is hospitalization after TIA cost-effective on the basis of treatment with tPA?. Neurology. 2005;65(11):1799–801. https://doi.org/10.1212/01.wnl.0000187067.93321.fa.CrossRefPubMed

14.

Griffiths D, Sturm J, Heard R, Reyneke E, Whyte S, Clarke T, O'Brien W, Crimmins D. Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?. J Clin Neurosci. 2014;21(1):47–50. https://doi.org/10.1016/j.jocn.2013.02.028.CrossRefPubMed

15.

Cucchiara BL, Kasner SE. All patients should be admitted to the hospital after a transient ischemic attack. Stroke. 2012;43(5):1446–7. https://doi.org/10.1161/strokeaha.111.636746.CrossRefPubMed

16.

Rahiman A, Saver JL, Porter V, Buxton W, McNair N, Razinia T, Ovbiagele B. In-hospital initiation of secondary prevention is associated with improved vascular outcomes at 3 months. J Stroke Cerebrovasc Dis. 2008;17(1):5–8. https://doi.org/10.1016/j.jstrokecerebrovasdis.2007.09.004.CrossRefPubMed

17.

Mijalski C, Silver B. TIA Management: should tia patients be admitted? Should TIA patients get combination antiplatelet therapy?. Neurohospitalist. 2015;5(3):151–60. https://doi.org/10.1177/1941874415580598.CrossRefPubMedPubMedCentral

18.

Edlow JA, Kim S, Pelletier AJ, Camargo CA Jr. National study on emergency department visits for transient ischemic attack, 1992-2001. Acad Emerg Med. 2006;13(6):666–72. https://doi.org/10.1197/j.aem.2006.01.014.CrossRefPubMed

19.

Bravata DM, Myers LJ, Cheng E, Reeves M, Baye F, Yu Z, Damush T, Miech EJ, Sico J, Phipps M, Zillich A, Johanning J, Chaturvedi S, Austin C, Ferguson J, Maryfield B, Snow K, Ofner S, Graham G, Rhude R, Williams LS, Arling G. Development and validation of electronic quality measures to assess care for patients with transient ischemic attack and minor ischemic stroke. Circ Cardiovasc Qual Outcomes. 2017;10(9). https://doi.org/10.1161/circoutcomes.116.003157.

20.

Damush TM, Miech EJ, Sico JJ, Phipps MS, Arling G, Ferguson J, Austin C, Myers L, Baye F, Luckhurst C, Keating AB, Moran E, Bravata DM. Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration. Neurology. 2017;89(24):2422–30. https://doi.org/10.1212/wnl.0000000000004739.CrossRefPubMedPubMedCentral

21.

Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA, Hankey GJ, Hart RG, Levine SR, Biller J, Brown RD, Jr., Sacco RL, Kappelle LJ, Koudstaal PJ, Bogousslavsky J, Caplan LR, van Gijn J, Algra A, Rothwell PM, Adams HP, Albers GW. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006;60(3):301–13. https://doi.org/10.1002/ana.20942.CrossRefPubMed

22.

Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-236. https://doi.org/10.1161/str.0000000000000024.CrossRefPubMed

23.

Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MS, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754–832. https://doi.org/10.1161/str.0000000000000046.CrossRefPubMedPubMedCentral

24.

Whisnant JP. Stroke: populations, cohorts, and clinical trials. Boston: Butterworth-Heinemann; 1993. 263 p.

25.

Handbook of Neuroepidemiology. In: Alter PBGaM, editor. New York: Marcel Dekker, Inc; 1994. p. 83–98.

26.

Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM, Catellier D, Murphy CV, Singh S, Tegeler CH, Felix A. A multicenter evaluation of the ABCD2 score’s accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack. Ann Emerg Med. 2010;55(2):201–10.e5. https://doi.org/10.1016/j.annemergmed.2009.05.002.CrossRefPubMed

27.

Edwards D, Cohn SR, Mavaddat N, Virdee SK, Lasserson D, Milner S, Giles M, McManus R, Mant J. Varying uses of the ABCD2 scoring system in primary and secondary care: a qualitative study. BMJ Open. 2012;2(6). https://doi.org/10.1136/bmjopen-2012-001501.CrossRefPubMedPubMedCentral

28.

Gattellari M, Goumas C, Garden F, Worthington JM. Relative survival after transient ischaemic attack: results from the Program of Research Informing Stroke Management (PRISM) study. Stroke. 2012;43(1):79–85. https://doi.org/10.1161/strokeaha.111.636233.CrossRefPubMed

29.

Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S. Minor stroke and transient ischemic attack: research and practice. Front Neurol. 2016;7:86. https://doi.org/10.3389/fneur.2016.00086.CrossRefPubMedPubMedCentral

30.

Oostema JA, Brown MD, Reeves M. Emergency Department Management of Transient Ischemic Attack: a survey of emergency physicians. J Stroke Cerebrovasc Dis. 2016;25(6):1517–23. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.02.028.CrossRefPubMed

31.

Furnham A. Response bias, social desirability and dissimulation. Personal Individ Differ. 1986;7(3):385–400. https://doi.org/10.1016/0191-8869(86)90014-0.CrossRef

32.

Sanders LM, Srikanth VK, Jolley DJ, Sundararajan V, Psihogios H, Wong K, Ramsay D, Phan TG. Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care. Stroke. 2012;43(11):2936–41. https://doi.org/10.1161/strokeaha.112.664060.CrossRefPubMed

33.

Ben-Yakov M, Kapral MK, Fang J, Li S, Vermeulen MJ, Schull MJ. The Association between emergency department crowding and the disposition of patients with transient ischemic attack or minor stroke. Acad Emerg Med. 2015;22(10):1145–54. https://doi.org/10.1111/acem.12766.CrossRefPubMed

34.

Dutta D, Bailey SJ. Validation of ABCD2 scores ascertained by referring clinicians: a retrospective transient ischaemic attack clinic cohort study. Emerg Med J 2016;33(8):543–7. https://doi.org/10.1136/emermed-2015-205519.CrossRefPubMed

35.

Li Q, Zhu X, Feng C, Fang M, Liu X. Duration of symptom and ABCD2 score as predictors of risk of early recurrent events after transient ischemic attack: a hospital-based case series study. Med Sci Monit. 2015;21:262–7. https://doi.org/10.12659/msm.892525.CrossRefPubMedPubMedCentral

36.

McKesson InterQual Actionable Evidence-Based Criteria Portfolio United States Department of Veterans Affairs; 2014.; LOC: Acute Adult; Stroke/TIA Subset. Available from: http://vaww.oqsv.med.va.gov/functions/integrity/um/InterQualBookView2010-2017/umInterQualBookView.aspx. Date last accessed: October 10, 2018.

Title: Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack
Authors: Barbara J. Homoya, RN, MSN
Teresa M. Damush, PhD
Jason J. Sico, MD, MHS
Edward J. Miech, EdD
Gregory W. Arling, PhD
Laura J. Myers, PhD
Jared B. Ferguson, BS
Michael S. Phipps, MD
Eric M. Cheng, MD, MS
Dawn M. Bravata, MD
Publication date: 01-09-2019
Publisher: Springer US
Published in: Journal of General Internal Medicine / Issue 9/2019
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-018-4735-9

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Abstract

Background

Objectives

Design

Participants

Approach

Key Results

Conclusions

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Objectives

Design

Participants

Approach

Key Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2019

Capsule Commentary on Bond et al., Real-time Feedback in Pay-for-Performance: Does More Information Lead to Improvement?

How Do We Address the Influence of Social Determinants on Health?

Changes in Price for Generic Drugs in the USA, 2008–2016

Effect of Electronic Clinical Decision Support on 25(OH) Vitamin D Testing

“That Was Pretty Powerful”: a Qualitative Study of What Physicians Learn When Preparing for Their Maintenance-of-Certification Exams

Automated Self-management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: the CAMMPS Randomized Clinical Trial

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page