Frequent inaccuracies in ABCD2 scoring in non-stroke specialists' referrals to a daily Rapid Access Stroke Prevention service

Bradley, David; Cronin, Simon; Kinsella, Justin A.; Tobin, W. Oliver; Mahon, Ciara; O'Brien, Margaret; Lonergan, Roisin; Cooney, Marie Therese; Kennelly, Sean; Collins, Rónán; O’Neill, Desmond; Coughlan, Tara; Smyth, Shane; McCabe, Dominick J. H.

doi:10.1016/j.jns.2013.05.030

Cited by 19 publications

(13 citation statements)

References 25 publications

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“…Two studies 10,20 provided sufficient information to calculate PPVs according to two referral routes (GP or ED doctor) and a further study provided information on PPVs for referrals purely from GPs. 27 One study gave PPVs predominantly from Banerjee et al (2009) 11 Bradley et al (2013) 12 Dutta et al (2015) 14 Dutta (2016) 15 Fallon et al (2006) 16 Ferro et al (1996) (GP route) 10 Ferro et al (1996) (ED route) 10 Fonseca and Canhão (2011) 26 Karunaratne et al (1999) 17 Lasserson et al (2015) 27 Lavallée et al (2007) 18 Lee and Frayne (2015) 19 Magin et al (2013) (GP route) 20 Magin et al (2013) (ED route) 20 Martin et al (1997) 25 Murray et al 2007 an ED setting, 16 whereas all other studies appeared to have largely comprised referrals from GPs. With the exception of one small study, 10 the PPVs appear lower in GP referrals than in referrals from ED doctors ( Table 1; Figures 2 and 3).…”

Section: Influence Of Referral Source and Referral Criterionmentioning

confidence: 99%

“…As such, it was not possible to compute sensitivity or specificity. This means that it was also not possible to interpret whether high predictive values were associated with Banerjee et al (2009) 11 Bradley et al (2013) 12 Dutta et al (2015) 14 Dutta (2016) 15 Fallon et al (2006) 16 Ferro et al (1996) (GP route) 10 Ferro et al (1996) (ED route) 10 Fonseca and Canhão (2011) (weekly clinic) 34 Fonseca and Canhão (2011) (daily clinic) a, 34 Freitas et al (2010) a, 35 Hall and Oczkowski (2010) a, 36 Karunaratne et al (1999) 17 Kleinig et al (2013) a, 24 Lasserson et al (2015) 27 Lavallée et al (2007) 18 Lebus et al (2012) a, 29 Lee and Frayne (2015) 19 Magin et al (2013) (GP route) 20 Magin et al (2013) (ED route) 20 Martin et al…”

Section: Strengths and Limitationsmentioning

confidence: 99%

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Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review

et al. 2017

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This study highlights the variation in prevalence of true vascular events in patients referred to TIA clinics. For patients without a cerebrovascular diagnosis, the high prevalence of conditions that also require specialist investigations and management are an additional burden on a care pathway that is primarily designed to prevent recurrent stroke. Service commissioners need to assess whether the existing outpatient provision is optimal for people with pathologies other than cerebrovascular disease.

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Section: Influence Of Referral Source and Referral Criterionmentioning

confidence: 99%

Section: Strengths and Limitationsmentioning

confidence: 99%

Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review

et al. 2017

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“…However, as per its original purpose, use of the score by nonexperts is encouraged, including with financial incentives to fast-track patients with ABCD2 score $4 to clinics in some countries. 8 Nurses now perform initial patient triage in about 30% of TIA clinics using the ABCD2 score, 11 but several studies indicate that the agreement for ABCD2 scoring between nonspecialists and vascular neurologists is only fair, 12,49,50 and the score has low sensitivity and specificity when used by nonspecialists in the community 12 or emergency department, 34 irrespective of the cutpoint used. 50 These limitations 50 have led to withdrawal of recommendation of the ABCD2 score from the Canadian stroke guidelines.…”

Section: 44mentioning

confidence: 99%

“…8 However, the ABCD2 score may have limitations for identifying important categories of patients, e.g., those with tight carotid stenosis or atrial fibrillation (AF), 9,10 and may not perform as well in the field as suggested in early reports and guidelines. 11,12 In view of these doubts, we assessed all available data to determine the extent to which the ABCD2 score had been tested in stroke prevention in circumstances in which guidelines now promote its use, and its ability to predict stroke recurrence in patients at high ($4) and low (,4) risk of stroke; differentiate patients with mimics from true stroke/TIA; identify carotid stenosis or AF; and estimate its effect on proportions of patients entering fast-or slow-track assessment in a typical stroke prevention service per 1,000 patients assessed.…”

mentioning

confidence: 99%

ABCD2 score and secondary stroke prevention

Wardlaw¹,

Brazzelli²,

Chappell³

et al. 2015

Neurology

131

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Editorial, page 304Supplemental data at Neurology.org ABCD2 score and secondary stroke prevention Meta-analysis and effect per 1,000 patients triaged ABSTRACT Objective: Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown.Methods: We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score ,/$4. We calculated the effect per 1,000 patients triaged on stroke prevention services.Results: Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 $4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent stroke within 7 days. Additionally, 20% of patients with ABCD2 ,4 had .50% carotid stenosis or atrial fibrillation (AF); 35%-41% of TIA mimics, and 66% of true TIAs, had ABCD2 score $4. Among 1,000 patients attending stroke prevention services, including the 45% with mimics, 52% of patients would have an ABCD2 score $4. Conclusion:The ABCD2 score does not reliably discriminate those at low and high risk of early recurrent stroke, identify patients with carotid stenosis or AF needing urgent intervention, or streamline clinic workload. Stroke prevention services need adequate capacity for prompt specialist clinical assessment of all suspected TIA patients for correct patient management.

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“…10 The ABCD 2 score is also less accurate when calculated by nonstroke physicians. 52 Given the doubts in the ABCD 2 score's ability to differentiate low-and high-risk stroke patients or those requiring urgent intervention for carotid stenosis or atrial fibrillation, 53 additional scores have been developed. Coutts and colleagues devised a more complex ABCD 2 þ MRI scoring system in which the ABCD 2 score items were retained and two MRI items added (presence of a diffusion weighted imaging [DWI] lesion and intracranial vessel occlusion).…”

Section: Risk Stratification In Tia: Getting It Rightmentioning

confidence: 99%

Organized Outpatient Care of Patients with Transient Ischemic Attack and Minor Stroke

Joundi

Saposnik

2017

Semin Neurol

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The risk of recurrent stroke after transient ischemic attack (TIA) is high. In the past 10 years, TIA has increasingly been recognized as a medical emergency. Health systems have adapted toward rapid evaluation, investigation, and secondary prevention in patients with presumed TIA and minor stroke, and the significant benefits in reducing recurrent stroke and mortality have been borne out in several landmark studies. Various scores have been developed and debated to better risk stratify patients with TIA for hospitalization or urgent referral. However, scoring systems face challenges in identifying all patients with high-risk etiologies such as atrial fibrillation and carotid stenosis, and therefore require further refinement before widespread use. Further challenges include the role of advanced imaging in TIA, and ensuring rapid access to specialist care for all patients. In the absence of definitive risk stratification methods, the authors conclude that all patients with suspected TIA and minor stroke should be assessed and treated on an urgent basis, ideally through rapid outpatient referral programs.

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Frequent inaccuracies in ABCD2 scoring in non-stroke specialists' referrals to a daily Rapid Access Stroke Prevention service

Abstract: The 'accuracy' of age, blood pressure, clinical features, duration and diabetes (ABCD 2 ) scoring by non-stroke specialists referring patients to a daily Rapid Access Stroke Prevention (RASP) service is unclear, as is the accuracy of ABCD 2 scoring by trainee residents.

Cited by 19 publications

References 25 publications

Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review

Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review

ABCD2 score and secondary stroke prevention

Organized Outpatient Care of Patients with Transient Ischemic Attack and Minor Stroke

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