Organized Outpatient Care

Abstract

Background and Purpose-Organized inpatient stroke care decreases mortality and morbidity irrespective of patient age, stroke severity, or stroke subtype. Limited information is available on whether organized outpatient care models such as stroke prevention clinics (SPC) improve outcomes after a transient ischemic attack or ischemic stroke. We compared 1-year mortality and stroke readmission in patients with transient ischemic attack or ischemic stroke referred versus not referred to an SPC. Methods-This was a retrospective cohort study including 16 468 consecutive patients with ischemic stroke or transient ischemic attack who were seen in the emergency department or admitted to a hospital between July 1, 2003 and March 31, 2008 at registry stroke centers (nϭ12) in the province of Ontario. Cox proportional hazards models and propensity score-matched analyses were used to evaluate 1-year mortality and readmission. Results-One-year mortality rates were lower in those referred to SPCs compared with those not referred, even after adjustment for age, sex, ethnic origin, income, comorbid conditions, stroke symptoms and severity, receipt of thrombolysis, stroke unit care, discharge destination, and functional status at discharge (adjusted hazard ratio [HR], 0.67; 95% CI, 0.60 -0.75). Survival analysis after propensity matching showed a 26% reduction in 1-year mortality (HR, 0.74; 95% CI, 0.65-0.84). There were no significant differences in 1-year readmission rates in those referred versus not referred to SPCs. Conclusions-Referral to an SPC is associated with a one-quarter reduction in mortality after ischemic stroke or transient ischemic attack. This supports the argument that outpatient stroke units may prove as effective as their inpatient counterparts. (Stroke. 2011;42:3176-3182.)

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

“…Similar to our study, Webster et al (2011) found that only 47% of the study population was referred to the neurovascular clinic in follow-up, indicating that outpatient neurovascular clinics may be underutilized. 9 Although we did not specifically look at reasons for non-referral, some reasons may include referral to a family doctor or community neurologist, failure to document a referral, and lack of awareness of the neurovascular clinic by the ED physician. Reasons for not being seen after referral may include patient noncompliance and miscommunication.…”

“…5,9,10 Using data from 12 specialized stroke centers in Ontario between 2003 and 2008, Webster et al (2011) found that referral of patients with ischemic stroke or TIA to a designated neurovascular clinic was associated with a 29% reduction in 1-year mortality (HR, 0.71; 95% CI, 0.65-0.84). Similar to our study, Webster et al (2011) found that only 47% of the study population was referred to the neurovascular clinic in follow-up, indicating that outpatient neurovascular clinics may be underutilized. 9 Although we did not specifically look at reasons for non-referral, some reasons may include referral to a family doctor or community neurologist, failure to document a referral, and lack of awareness of the neurovascular clinic by the ED physician.…”

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

“…However, our study setting closely resembles the United Kingdom National Health Service and integrated managed care organizations in the United States, and the clinical profiles of our participants were similar to recent reports of stroke survivors from other Canadian provinces, the US, the UK and Europe. 1,2,10,20,24,25,28 When considering the external validity of our results, the under-treatment of vascular risk factors is a nearly universal phenomenon and has been documented in many other settings and for other atherosclerotic conditions.…”

Adherence to Guidelines: Experience of a Canadian Stroke Prevention Clinic

“…2 Reducing the rate of recurrent stroke requires identifying and controlling modifiable risk factors in the early poststroke/transient ischemic attack (TIA) period and developing appropriate preventive strategies. 1,[3][4][5][6] The identification and control of modifiable vascular risk factors (MRFs) is one of the main goals of stroke prevention clinics (SPCs) in addition to appropriate use of antithrombotics and selective surgical interventions as suggested by current practice guidelines. 1,6,7 Unfortunately, a relatively high proportion of patients fail to achieve the recommended therapeutic objectives.…”

“…[8][9][10] Recent evidence in the literature suggests that improving outpatient care through referral to SPCs may decrease risk of adverse outcomes. 3 We retrospectively assessed the effectiveness and impact of our SPC in achieving therapeutic targets for vascular risk factors and appropriate medical and surgical interventions. We also assessed adherence to prescribed drug therapy and its impact on the attainment of therapeutic goals.…”