Implications of research findings for care quality and quality improvement initiatives
| Key finding (direction of effect) | Implications for care quality and future quality improvement work |
| Care quality | |
| Speech deficit at presentation (+) | Presence of a speech deficit or other symptom may reduce diagnostic uncertainty. However, many patients with a TIA may have minimal, if any, overt symptoms by the time they seek care. |
| Higher CCI (+) | More medically complex patients may require inpatient admission for testing related to their presentation to differentiate symptoms that may be referential to an illness or to focal cerebrovascular ischemia (eg, hypoglycaemia among a patient with diabetes resulting in slurred speech). These patients may also present with concomitant worsening of a chronic medical illness or a new unrelated medical problem. Given that patients with CCI have poorer outcomes, earlier receipt of necessary TIA care may improve outcomes. |
| Inpatient admission (+) | Inpatient admission can increase the timeliness which patients receive guideline concordant evaluation (brain and carotid imaging) and management (receipt of high or moderate potency statin and antithrombotic medication) while enhancing access to Neurologist consultation. An alternative solution to inpatient admission includes increasing the availability of outpatient TIA assessment clinics. |
| Neurology consultation (+) | Neurologists may be more apt to provide evidence-based recommendations for patients with TIA. In the absence of on-site neurologists, innovative programmes to enhance access to specialty care include the use of telehealth and/or developing and implementing standardised, evidence-based protocols. |
| Receiving neurology consultation | |
| Inpatient admission (+) | Given decreased access to neurologists in the outpatient setting, ED providers may opt to admit patients with TIA to improve timely access to neurologist consultation. |
| Stroke centre designation (+) | These facilities have created systems to improve care delivery to patients with cerebrovascular events. |
| Facility complexity (+) | More complex facilities typically have greater availability of on-site specialty care providers. |
| Dementia (−) | May be secondary to the known association of dementia with lower care quality. Healthcare providers may embrace diagnostic and therapeutic nihilism when attending to patients with dementia and a TIA. The TIA may have been attributed to the dementia by the non-neurologist provider. While the presence of dementia did not negatively impact the quality indicator score, facilities should strive to provide access to needed post-TIA care regardless of cognitive function. |
| Higher CCI (−) | As these patients are more likely to have worsening of medical illness, these conditions may take priority over being evaluated by a neurologist. However, once a medical condition is attended to and a patient is more stable, appropriate post-TIA care should be delivered. |
| Weekend arrival (−) | Likely secondary to decreased availability of after-hours neurological consultation. Alternatives include developing protocols to improve access to neurologists with other VA medical centres (eg, via telehealth) or partnering with community hospitals which have greater availability of neurologists. |
| Fewer FTE Neurology staff (−) | If fewer neurologists are available within a medical centre, there is a decreased likelihood of patients with TIA seeing a neurologist. |
| Inpatient admission | |
| Speech deficit at presentation (+) | Speech deficit is a component of the ABCD2 score, which is used to estimate risk of stroke after a suspected TIA and factors into consideration for admission, with higher ABCD2 scores leading to higher rates of admission. |
| Higher CCI (+) | More medically complex patients may have multiple reasons for admission. |
| Fewer FTE Neurology staff (−) | If fewer neurologists are available within a given medical centre, ED and other providers may contend that there is less that they could offer patients with TIA or they may be less aware of TIA-care recommendations. Increased awareness and implementation of protocols to enhance delivery of best practices in TIA care should be considered. |
Light blueshading indicates a positive association; light orange shading indicates a negative association.
CCI, Charlson Comorbidity Index; ED, emergency department; FTE, full-time equivalent; TIA, transient ischemic attack; VA, Veterans Affairs.