O'Brien Emily C, Zhao Xin, Fonarow Gregg C, Schulte Phillip J, Dai David, Smith Eric E, Schwamm Lee H, Bhatt Deepak L, Xian Ying, Saver Jeffrey L, Reeves Mathew J, Peterson Eric D, Hernandez Adrian F
From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.).
Circ Cardiovasc Qual Outcomes. 2015 Oct;8(6 Suppl 3):S117-24. doi: 10.1161/CIRCOUTCOMES.115.002048.
Patients with transient ischemic attack (TIA) are at increased risk for ischemic stroke. We derived a prediction rule for 1-year ischemic stroke risk post-TIA, examining estimated risk, receipt of inpatient quality of care measures for TIA, and the presence or absence of stroke at 1 year post discharge.
We linked 67 892 TIA Get With The Guidelines-Stroke patients >65 years (2003-2008) to Medicare inpatient claims to obtain longitudinal outcomes. Using Cox proportional hazards modeling in a split sample, we identified baseline demographics and clinical characteristics associated with ischemic stroke admission during the year post-TIA, and developed a Get With The Guidelines Ischemic Stroke after TIA Risk Score; performance was examined in the validation sample. Quality of care was estimated by a global defect-free care measure, and individual performance measures within estimated risk score quintiles. The overall hospital admission rate for ischemic stroke during the year post-TIA was 5.7%. Patients with ischemic stroke were more likely to be older, black, and have higher rates of smoking, previous stroke, diabetes mellitus, previous myocardial infarction, heart failure, and atrial fibrillation. The Risk Score showed moderate discriminative performance (c-statistic=0.606); highest quintile patients were less likely to receive statins, smoking cessation counseling, and defect-free care. Although not associated with 1-year ischemic stroke, DCF was associated with a significantly lower risk of all-cause mortality.
TIA patients with high estimated ischemic stroke risk are less likely to receive defect-free care than low-risk patients. Standardized risk assessment and delivery of optimal inpatient care are needed to reduce this risk-treatment mismatch.
短暂性脑缺血发作（TIA）患者发生缺血性卒中的风险增加。我们推导了TIA后1年缺血性卒中风险的预测规则，研究了估计风险、TIA住院质量护理措施的接受情况以及出院后1年有无卒中。
我们将67892例年龄>65岁的TIA“遵循指南-卒中”患者（2003 - 2008年）与医疗保险住院索赔数据相链接，以获得纵向结局。在一个分割样本中使用Cox比例风险模型，我们确定了与TIA后1年内缺血性卒中入院相关的基线人口统计学和临床特征，并开发了TIA后缺血性卒中“遵循指南”风险评分；在验证样本中检验了其性能。通过整体无缺陷护理措施以及估计风险评分五分位数内的个体性能指标来估计护理质量。TIA后1年内缺血性卒中的总体住院率为5.7%。发生缺血性卒中的患者更可能年龄较大、为黑人，且吸烟、既往卒中、糖尿病、既往心肌梗死、心力衰竭和心房颤动的发生率较高。风险评分显示出中等的鉴别性能（c统计量 = 0.606）；最高五分位数的患者接受他汀类药物、戒烟咨询和无缺陷护理的可能性较小。尽管与1年缺血性卒中无关，但DCF与全因死亡率显著降低的风险相关。
估计缺血性卒中风险高的TIA患者比低风险患者接受无缺陷护理的可能性更小。需要进行标准化风险评估并提供最佳住院护理，以减少这种风险 - 治疗不匹配的情况。
