From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
Neurology. 2023 May 16;100(20):e2093-e2102. doi: 10.1212/WNL.0000000000207201. Epub 2023 Mar 28.
Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA.
In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model.
We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; = 0.65) nor slope change (parameter estimate 0.30; = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention.
The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded.
This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.
降低因短暂性脑缺血发作（TIA）导致的卒中复发率颇具挑战，尤其是在农村和偏远地区。在加拿大艾伯塔省，尽管有组织完善的卒中体系，但 1999 年至 2000 年的数据显示，TIA 后 90 天内的卒中复发率高达 9.5%。我们的目的是确定多方面的基于人群的干预措施是否会降低 TIA 后的复发性卒中。
在这项准实验性卫生服务研究干预研究中，我们在全省范围内实施了 TIA 管理算法，以 24 小时医生 TIA 热线和公众以及医疗保健提供者的 TIA 教育为中心。从管理数据库中，我们将急诊出院摘要与医院出院摘要相关联，以确定单一支付者系统中 90 天内的 TIA 事件和复发性卒中，并对复发性卒中事件进行验证。主要结局是复发性卒中；次要复合结局是复发性卒中、急性冠状动脉综合征和全因死亡。我们使用年龄和性别调整后的 TIA 后卒中复发率的中断时间序列回归分析，纳入 2 年的实施前阶段（2007-2009 年）、15 个月的实施阶段和 2 年的实施后阶段（2010-2012 年）。使用逻辑回归来检验不符合时间序列模型的结果。
我们在实施前评估了 6715 例患者，实施后评估了 6956 例患者。在艾伯塔省 TIA 和轻度卒中预防中的 ASPIRE 前阶段，90 天内的卒中复发率为 4.5%，而 ASPIRE 后阶段为 5.3%。ASPIRE 干预实施期间，复发卒中率既没有发生阶跃变化（估计值 0.38； = 0.65），也没有斜率变化（参数估计值 0.30； = 0.12）。ASPIRE 干预后，全因死亡率（比值比 0.71，95%CI 0.56-0.89）显著降低。
在组织完善的卒中体系中，ASPIRE TIA 分诊和管理干预措施并未进一步降低卒中复发率。干预后明显较低的死亡率可能与事件识别为 TIA 后监测的改善有关，但不能排除长期趋势。
本研究提供了 III 级证据，表明针对 TIA 患者的标准化人群算法分诊系统并未降低复发性卒中率。
