Enhancement of TIA management in primary care with a novel electronic tool.
نویسندگان
چکیده
Cerebrovascular disease causes a heavy burden for society. To avoid disability and reduce costs, stroke prevention is essential. The Early Use of Existing Preventive Strategies for Stroke (EXPRESS) and Transient Ischemic Attack Clinic with Round-the-Clock Access (SOS-TIA) studies in Oxfordshire and Paris suggested that rapid investigation and treatment can prevent early stroke in TIA patients. Neurologistled rapid access clinics are not available to all, however, and it is general practitioners (GPs) who most commonly play the crucial role in early management, making the diagnosis and urgent transfer to hospital, or initiating tests and treatments and triaging patients to the appropriate specialist clinic, including determining the urgency of referral. Individual GPs see few such patients, however, and their knowledge of TIA diagnosis and urgent investigations and secondary prevention treatments is not always optimal. The current goals of TIA management are timely (,24 hours) evaluation by a stroke team and hospitalization for high-risk patients, while low-risk patients should complete the diagnostic workup within 7 days from onset. The TIA clinics, custom-made for lowrisk patients, have shown good feasibility and safety indices. These clinics offer evaluation by neurologists and completion of diagnostic tests in a variably short period of time, usually 7 days. Any pathway designed to improve the primary care phase of TIA management needs to consider GPs’ diagnostic accuracy, their guideline awareness and access, and local availability of diagnostic studies and specialist advice. In view of the difficulties GPs face in the urgent management of TIA, Lavin and Ranta developed an electronic decision support tool to enhance GPs’ decision-making by means of quick, Web-based access to current guidelines and prompts about risk stratification and TIA management strategies. The tool has shown good results in terms of feasibility, efficacy, and safety. Now, in this issue of Neurology®, Ranta et al. report the results of a cluster randomized trial, comparing a group of TIA decision tool–supported GP practices to a group of practices without the tool. Guideline adherence and 90-day stroke rates were the primary outcome measures. Before patient enrollment, both groups received education about TIA/ stroke management and the New Zealand TIA Guidelines. The authors observed an improvement in guideline adherence, and a reduction in treatment costs for the intervention group, but no clear difference in the stroke rate, which was low in both groups. The rate of vascular events and death overall were lower in the intervention group. The low stroke rate in the control group may have a number of explanations, including the education provided to the control practice GPs, as the authors point out. Investigators planning future trials in TIA will need to be cautious in their sample size calculations and look beyond the ABCD2 literature for the control rate. With the exception of some imbalance of the 2 arms of the trial, caused by some unintended enrollments, and greater recruitment in one of the intervention GP practices, the study was well-conducted and the results are convincing. The tool appears to be useful in helping GPs in their clinical practice, with reassuring outcome results. GP feedback on the usefulness and acceptability of the tool was high. Referral center stroke physicians found that the quality of referrals improved and stroke prevention therapy was prescribed earlier in the intervention group. During the study period, the tool-supported system saw only one failure in risk prediction, an early stroke in a TIA patient who was triaged as low risk, due more likely to a deficiency in current guidelines than to any error of the tool. The tool has been appropriately named a decision support tool. It was not designed to be a substitute for clinical evaluation and doctors’ knowledge, but to help GPs rapidly consult current evidence, make a quick risk stratification, and avoid adverse outcomes for their patients. It was not designed for use by nonmedical health care workers.
منابع مشابه
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ورودعنوان ژورنال:
- Neurology
دوره 84 15 شماره
صفحات -
تاریخ انتشار 2015