The burden and management of TIA and stroke in the Veterans Administration and Department of Defense.

Transient ischemic attack (TIA) and stroke are commonly occurring cerebrovascular events that require prompt and appropriate treatment to reduce the risk of secondary stroke. The US Department of Veterans Affairs (VA) and the Department of Defense constitute 2 large medical systems treating military personnel, both active and retired, as well as many of their dependents. In the area of stroke and TIA management, the VA in particular has instituted far-reaching measures, including those to ensure adherence to clinical treatment guidelines shown to produce optimal outcomes in stroke. The result of these measures has been that VA patients experience lower morbidity and mortality risk, as well as lower rates of stroke-related rehospitalization, than comparable patients treated through Medicare and Medicaid and in university hospitals. These successes in part may be an advantage derived from a relatively closed system with sufficient administrative discipline to maintain clinical guidelines treatment standards. It may also be the case that continuity of care in these systems produces better outcomes than more fragmentary treatment that may be experienced in the civilian realm. In addition, the VA system avoids incentivizing physicians for performing medical services, and instead incentivizes quality of care, which may provide a further advantage for patients treated within that system.