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Age and Ageing Advance Access originally published online on July 26, 2007
Age and Ageing 2007 36(6):676-680; doi:10.1093/ageing/afm088
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Substantial underestimation of the need for outpatient services for TIA and minor stroke

Matthew F. Giles and Peter M. Rothwell

Stroke Prevention Research Unit, Oxford University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HA, UK

Address correspondence to: Matthew F. Giles. Tel: 01865 617158; Fax: 01865 617160. Email: Matthew.Giles{at}clneuro.ox.ac.uk


   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Key points
 Conflict of Interests
 References
 
Objectives: to measure the number of all transient ischaemic attack (TIAs) and minor strokes managed as outpatients, and hence, the need for ‘TIA clinics’ in comparison to current estimates of 20,000 TIAs annually in England, based on previous rates of incident-definite events.

Subjects: all individuals with confirmed or suspected TIA or stroke between 2002 and 2005 in a population-based study of 91,105 individuals in Oxfordshire, UK.

Outcome Measures: numbers, rates, and risks of recurrent stroke for incident-definite TIA, any probable or definite TIA, stroke, and all referrals of suspected TIA and stroke, stratified according to inpatient versus outpatient management.

Results: of 1,174 confirmed or suspected events ascertained, 729 (62.1%) were managed as outpatients and 445 (37.9%) as inpatients. Among 757 probable or definite events, 432 (57%) were managed as outpatients. Incident-definite TIAs accounted for only 18% of all referrals to outpatient services. Annual rates per 1,000 population were 2.98 (2.77–3.2) for all referrals to outpatient services and 1.88 (1.71–2.06) for inpatient admissions. Of 73 recurrent strokes within 90 days of initial TIA or stroke, 48 (65.8%) occurred in the outpatient population. Applying these rates to the population of England yields approximately 150,000 new referrals annually to TIA clinics with about 10,000 early recurrent strokes.

Conclusion: more patients with TIA or stroke are managed as outpatients than inpatients in the UK, and this group has the majority of possibly preventable early recurrent strokes. Current projections of need for TIA clinics in England substantially underestimate the overall requirement for outpatient services.

Keywords: TIA, stroke, outpatients, inpatients, TIA clinic, elderly


   Introduction
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 Abstract
 Introduction
Methods
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 Key points
 Conflict of Interests
 References
 
In the UK, there is widespread agreement on the need for improved inpatient services for major stroke [1, 2]. Most emphasis has been on increasing the provision of thrombolysis in the acute phase, stroke units and post-discharge support services [1], which have been monitored in regular national audits [2]. In contrast, the importance of efficient clinical services for transient ischaemic attack (TIA) and non-disabling stroke has only recently been fully recognised. The risk of stroke after a TIA or minor stroke is as high as 10% within the first week [3–5], clinical scores are now available to predict individual risk [3, 5], the need for urgent carotid endarterectomy in patients with symptomatic stenosis has been established [6] and studies of early medical treatment are ongoing [7, 8].

In the UK, patients with TIA and minor stroke are generally managed as outpatients. The National Service Framework for Older People required all hospital trusts to have rapid-access referrals protocols in place by 2004, [9] and the Royal College of Physicians (RCP) recommends that patients should be seen within 1 week [1]. However, the 2006 National Sentinel Stroke Audit found that 22% of hospital trusts treating stroke patients did not offer TIA clinics and 65% were unable to assess patients within 7 days, with a median time from event to clinical review of 12 days (IQR 7–17) [2]. Similarly, the 2005 National Audit Office (NAO) report highlighted general practitioners’ (GPs) difficulties in accessing TIA clinics [10].

The UK Department of Health DoH is committed to improving services for TIA and minor stroke [11] but there are no reliable data on the capacity required. Current estimates are derived from the Oxfordshire Community Stroke Project (OCSP), the only previous population-based incidence study of TIA in the UK [12], but the study was conducted 25 years ago and used a stringent definition of definite, ‘first-ever-in-a-lifetime’ TIA, as did the few available studies from other countries [13, 14]. This research-based definition excluded many patients who would be expected to be managed in TIA clinics, such as those with recurrent TIA, non-disabling stroke and suspected TIA or stroke in whom an alternative diagnosis is eventually made. The NAO [10] and DoH [11] estimate that 20,000 incident TIAs occur in England every year and a ‘rule of thumb’ doubling of numbers is sometimes used to take into account patients with non-vascular diagnoses [15, 16]. However, the actual demand for TIA clinics in the UK has never been reliably measured. We therefore aimed to measure the numbers of confirmed or suspected TIAs or strokes managed as outpatients versus inpatients and the rate of recurrent stroke in each group in a population-based study.


   Methods
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 Abstract
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 Methods
Results
 Discussion
 Supplementary data
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The Oxford Vascular Study (OXVASC) is a population-based study of stroke and TIA in 91,105 individuals of all ages registered with nine general practices in Oxfordshire, UK. The study methods have been described elsewhere [17]. Briefly, multiple overlapping methods of ‘hot’ and ‘cold’ pursuit were used to achieve near-complete ascertainment of all individuals with TIA or stroke. These include:

  1. A daily, rapid-access TIA clinic to which participating GPs and the local accident and emergency department (A&E) refer all individuals with suspected TIA or stroke whom they would not normally admit to hospital.
  2. Daily searches of admissions to the medical, stroke, neurology and other relevant wards.
  3. Daily searches of the local A&E attendance register.
  4. Monthly searches of GP diagnostic coding and hospital discharge codes.
  5. Monthly searches of all cranial and carotid imaging studies performed in local hospitals.

All patients referred to the study clinic were assessed as soon as possible by a clinical fellow. A pragmatic definition of definite or probable TIA was used to include any transient symptoms (either incident or recurrent) lasting less than 24 h of likely vascular aetiology that was felt to justify secondary prevention treatment. A standard definition of stroke was used [18]. Imaging was CT based and was not used in the differentiation of TIA and stroke; patients with symptoms lasting less than 24 h with an ischaemic lesion on imaging were therefore classified as TIA. Patients referred to the clinic or admitted to hospital with a suspected cerebrovascular event, and in whom an alternative diagnosis was made following specialist assessment and cranial imaging were classified as ‘referral with non-cerebrovascular diagnosis’. Multiple events (usually multiple TIAs) leading to a single contact with medical services were counted as one event, and routine follow-up clinic attendances were excluded. Events were classified as either ‘clinic’ or ‘inpatient’ according to where they were managed; a patient who attended A&E and was referred to the clinic where treatment and imaging were initiated was classified as having a ‘clinic’ event, while a patient referred to the clinic but who required immediate hospital admission was classified as an ‘inpatient’ event. Out-of-hospital stroke-related deaths, and patients who were treated solely at home, were excluded. Patients with sub-arachnoid haemorrhage were excluded, as they are not usually managed by stroke services in the UK.

All patients were followed up at 1 and 6 months by a study nurse, and if a recurrent stroke was suspected, they were reassessed by a clinician. Recurrent stroke was defined as any stroke following clinical assessment, which occurred after a period of neurological stability; events on the same day were therefore considered while those occurring prior to first assessment (either as outpatient or inpatient) were excluded from analysis.

The study period was from April 2002 to March 2005. Incidence rates were standardised to the 2005 population of England [19]. Numbers of expected events for a standard district general hospital (DGH) serving a population of 330,000 and for the population of England were estimated by applying measured standardised incidence rates to the population of interest. The OXVASC study was approved by the local ethics committee.


   Results
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 Introduction
 Methods
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Discussion
 Supplementary data
 Key points
 Conflict of Interests
 References
 
In the 3-year study period, 1,174 events occurred in 1,094 individuals. Of a total of 260 probable or definite TIAs, 129 (50%) were definite, first-ever-in-a-lifetime (incident), the remainder being either recurrent events [69 (27%)] or probable TIAs treated with secondary prevention [62 (24%)]. These incident-definite TIAs accounted for only 18% (129/729) of all referrals of suspected TIA or minor stroke to outpatient services. Table 1 compares total numbers and standardised incidence rates for incident-definite TIA, any probable or definite, incident or recurrent TIA and stroke. The rate for incident-definite TIA (whether clinic or inpatient) was 0.54 (0.44–0.63) per thousand population compared with 1.08 (0.95–1.21) for any probable or definite, incident or recurrent TIA.


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  		Table 1. Crude and standardised (to the 2005 population of England) annual incidence rates per thousand population for incident-definite TIA, any probable or definite TIA, and stroke

 
Of 757 probable or definite TIAs or strokes, 432 (57%) were managed as outpatients. Of all 1,174 suspected TIAs or stroke, 729 (62.1%) episodes in 694 individuals were managed as outpatients, and comprised 233 (32.0%) TIAs, 209 (28.7%) strokes and 287 (39.4%) referrals with non-cerebrovascular diagnoses, the commonest being migraine, syncope and undetermined diagnosis. The mean National Institutes of Health Stroke Scale (NIHSS) [20] score for 209 clinic strokes was 1.8 (SD 1.9, range 0–8).

Of 445 inpatient episodes in 427 individuals, 298 (67.0%) were for stroke, 27 (6.1%) for TIA and 120 (27.0%) were for referrals with non-cerebrovascular diagnoses. Table 2 compares total numbers and standardised incidence rates for outpatients versus inpatients.


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  		Table 2. Crude and standardised (to the 2005 population of England) annual incidence rates per thousand population for clinic and inpatient strokes and TIAs and overall activity

 
Estimated total numbers of patient episodes for an average DGH serving a 330,000 population and the 2005 population of England (calculated by applying the measured standardised incidence rates) are given in Table 3 and indicate that a DGH may expect approximately 1,000 new referrals per year in a ‘TIA clinic’ (about 20 per week).


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  		Table 3. Projected total numbers of events for an average district general hospital serving 330,000 people and for the estimated 2005 population of England (calculated by applying standardized incidence rates to the population of interest)

 
Follow-up was completed in 90 days. Seventy-three recurrent strokes occurred during the 90 days after patients had sought medical attention following an initial probable or definite TIA or stroke. Forty-eight of these strokes (65.8%) occurred in patients who were referred for outpatient assessment. Applying these rates to the 2005 population of England would yield 9,920 early recurrent strokes per year in patients referred to TIA clinics. Appendix Figure 1 on the journal website (http://www.ageing.oupjournals.org/) shows a Kaplan Meier curve for recurrent stroke for out- and inpatients following initial TIA or stroke.


   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
Supplementary data
 Key points
 Conflict of Interests
 References
 
The UK DoH projections of need for TIA clinics are based on previous studies of incident-definite TIA, but we have shown that incident-definite TIAs account for only about 18% of all referrals of suspected TIA or minor stroke to outpatient services. Although our projection of about 26,000 incident TIAs likely to occur in England each year is similar to the estimate of 20,000 per year derived from the OCSP in 1981–86, we calculate that about 48,000 probable or definite TIAs and 43,000 minor strokes are managed as outpatients each year in England, and a total of 150,000 new referrals to TIA clinics should be expected. About 10,000 possibly preventable early recurrent strokes will occur each year in this group.

There have been few population-based studies of TIA incidence, and all of these have used narrow, research-based definitions of definite TIA, excluding patients with previous TIA or stroke and patients with probable TIA who are investigated and treated in the same way as definite TIAs. Our incidence rate for incident-definite TIA was 0.54 (95% CI 0.44–0.63) per thousand population, somewhat higher than the rate of 0.42 measured in the same population in the 1980s [12]. Comparable studies elsewhere have estimated standardised incidence rates of TIA of 0.42 (0.33–0.54) in Italy between 1986 and 1989 [21], 0.21 (0.12–0.30) in Spain in 1992–94 [22], 0.58 in Italy in 1992–93 [23] and 0.27 (0.09–0.79) in Russia in 1996–97 [24]. The difference in measured rates is partly explained by the use of different definitions, but also by better ascertainment of cases by OXVASC, especially in the elderly [17].

Although we believe that our conclusions are valid, our study does have some shortcomings. First, while we aimed not to influence normal referral practice, the numbers of patients attending the study clinic may have been affected by the clinic's availability. However, the proportions of TIAs and strokes to referrals with non-cerebrovascular diagnoses are similar to other published cohorts from (non-research based) TIA clinics [15, 16, 25] and the low NIHSS stroke severity score in clinic attenders with stroke indicates that such patients would not generally have been admitted to hospital elsewhere in the UK. Future usage of TIA clinics is expected to change as recent RCP guidance [1] recommends inpatient management for some patients with minor stroke and high-risk TIA while the large number of TIA patients who are currently managed in general medical, geriatric and neurology clinics [26] may increasingly be referred to specialist services. Secondly, Oxfordshire is more affluent than some other parts of the UK, and therefore, possibly has lower rates of atherosclerotic disease. However, although the electoral wards containing our practices are significantly less deprived than the rest of England, they include a broad range of deprivation with 22% of wards ranking in the lower third nationally [27]. Moreover, standardised rates of admission to hospital for stroke in Oxfordshire are similar to the mean overall rate in England [28] and our estimated number of annual admissions for stroke in England (63,515) is similar to that observed in 2003–04 (65,108) [29], suggesting that our results are likely to be generalisable. Finally, the OXVASC population is 94% white [30] and our results are not necessarily applicable to areas with a very different ethnic mix.

In summary, we have shown that the numbers of patients managed in TIA clinics is considerable, and is divided roughly equally between TIA, non-disabling stroke and suspected TIA. This number is far greater than previous estimates of a TIA clinic workload, based on earlier TIA incidence data and greater than the numbers of patients with stroke or TIA managed as inpatients.


   Supplementary data
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
Key points
 Conflict of Interests
 References
 
Supplementary data for this article is available online at http://ageing.oxfordjournals.org.


   Key points
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Key points
Conflict of Interests
 References
 

  • The risk of stroke after TIA or minor stroke is approximately 10% at 1 week, and guidelines therefore recommend rapid assessment; in the UK, the standard means of managing such patients is in TIA clinics.
  • The UK Department of Health (DOH) projections of need for TIA clinics are based on previous studies of incident-definite TIA, which estimate that about 20,000 TIAs occur in England each year.
  • Incident-definite TIAs account for only about 18% of all referrals of suspected TIA or minor stroke to outpatient services.
  • At least 48,000 probable or definite TIAs, and 43,000 minor strokes are managed as outpatients each year in England, and a total of 150,000 new referrals to TIA clinics should be expected.
  • About two-thirds of all referrals of suspected TIA and stroke in the UK are managed by outpatient services, and about 10,000 early recurrent strokes occur each year in this group.


   Conflict of Interests
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Key points
 Conflict of Interests
References
 
None


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Key points
 Conflict of Interests
 References
 

  1. Intercollegiate Working Party for Stroke. National Clinical Guidelines for Stroke. (2004) London: Royal College of Physicians.
  2. Intercollegiate Stroke Working Party. National Sentinal Stroke Audit. (2006) London: Clinical Effectiveness and Evaluation Unit, Royal College of Physicians.
  3. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet (2007) 369:283–92.[CrossRef][Web of Science][Medline]
  4. Coull AJ, Lovett JK, Rothwell PM, Oxford Vascular Study. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ (2004) 328:326–8.[Abstract/Free Full Text]
  5. Rothwell PM, Giles MF, Flossmann E, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet (2005) 366:29–36.[CrossRef][Web of Science][Medline]
  6. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ, Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet (2004) 363:915–24.[CrossRef][Web of Science][Medline]
  7. Kennedy J, Eliasziw M, Hill MD, Buchan AM. The Fast Assessment of Stroke and Transient Ischemic Attack to prevent Early Recurrence (FASTER) Trial. Seminars in Cerebrovascular Disesases and Stroke (2003) 3:25–30.[CrossRef]
  8. Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic attacks and minor ischaemic strokes. Lancet Neurol (2006) 5:323–31.[CrossRef][Web of Science][Medline]
  9. Department of Health. National Service Framework for Older People. (2001) London: Department of Health:.
  10. National Audit Office. Reducing Brain Damage: Faster Access to Better Stroke Care. (2004) London: Department of Health.
  11. Department of Health. Mending Hearts and Brains. (2006) London: Department of Health.
  12. Dennis MS, Bamford JM, Sandercock PA, Warlow CP. Incidence of transient ischemic attacks in Oxfordshire, England. Stroke (1989) 20:333–9.[Abstract/Free Full Text]
  13. Brown RD Jr, Petty GW, O'Fallon WM, Wiebers DO, Whisnant JP. Incidence of transient ischemic attack in Rochester, Minnesota, 1985–1989. Stroke (1998) 29:2109–13.[Abstract/Free Full Text]
  14. Lemesle M, Milan C, Faivre J, Moreau T, Giroud M, Dumas R. Incidence trends of ischemic stroke and transient ischemic attacks in a well-defined French population from 1985 through 1994. Stroke (1999) 30:371–7.[Abstract/Free Full Text]
  15. Blight A, Pereira AC, Brown MM. A single consultation cerebrovascular disease clinic is cost effective in the management of transient ischaemic attack and minor stroke. J R Coll Physicians Lond (2000) 34:452–5.[Web of Science][Medline]
  16. Karunaratne PM, Norris CA, Syme PD. Analysis of six months' referrals to a "one-stop" neurovascular clinic in a district general hospital: implications for purchasers of a stroke service. Health Bull (Edinb) (1999) 57:17–28.[Medline]
  17. Rothwell PM, Coull AJ, Giles MF, et al, Oxford Vascular Study. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet (2004) 363:1925–33.[CrossRef][Web of Science][Medline]
  18. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ (1976) 54:541–53.[Web of Science][Medline]
  19. http://www.statistics.gov.uk.
  20. Brott TG, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke (1989) 20:864–70.[Abstract/Free Full Text]
  21. Ricci S, Celani MG, Guercini G, et al. First-year results of a community-based study of stroke incidence in Umbria, Italy. Stroke (1989) 20:853–7.[Abstract/Free Full Text]
  22. Sempere AP, Duarte J, Cabezas C, Claveria LE. Incidence of transient ischemic attacks and minor ischemic strokes in Segovia, Spain. Stroke (1996) 27:667–71.[Abstract/Free Full Text]
  23. Lauria G, Gentile M, Fassetta G, et al. Incidence of transient ischemic attacks in the Belluno Province, Italy. First-year results of a community-based study. Acta Neurol Scand (1996) 93:291–6.[Web of Science][Medline]
  24. Feigin VL, Shishkin SV, Tzirkin GM, et al. A population-based study of transient ischemic attack incidence in Novosibirsk, Russia, 1987–1988 and 1996–1997. Stroke (2000) 31:9–13.[Abstract/Free Full Text]
  25. Martin PJ, Young G, Enevoldson TP, Humphrey PR. Overdiagnosis of TIA and minor stroke: experience at a regional neurovascular clinic. QJM (1997) 90:759–63.[Abstract/Free Full Text]
  26. Birns J, Vilasuso M, Cohen DL. One-stop clinics are more effective than neurology clinics for TIA. Age Ageing (2006) 35:306–8.[Free Full Text]
  27. 2001 Census Area Statistics. (2001) London: Stationary Office.
  28. Goldacre M, Yeates D, Leicester G, McGuiness H, Meddings D. Other strokes in England 1998/9 to 2002/3. A geographical profile of hospital admissions. (2005) Unit of Health Care Epidemiology, Oxford University and South East England Public Health Observatory.
  29. http://www.nchod.nhs.uk.
  30. Department of the Environment, Transport and the Regions. (2001) Indices of Deprivation. Stationary Office: London.
Received 21 February 2007; accepted in revised form 16 May 2007.


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