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Our rapid assessment stroke clinic (RASC) was established as part of a single point of access for general practitioners to refer patients with suspected transient cerebral or ocular ischaemic attacks (TIA) or recovered non-hospitalised stroke in response to the publication of the National Clinical Guidelines for Stroke1 and the National Service Framework for Older People.2 Similar rapid access neurovascular clinics have been set up throughout the United Kingdom to provide readily available access to primary care for the management of similar patients. These clinics have significant revenue costs for the NHS, and hence the importance of reviewing their process and outcome. We now report the fate of non-attendees to highlight the risk of early stroke.
Between October 2000 and December 2002, 1460 patients were referred to the RASC. When a referral (usually by phone or fax) is received, the patient is contacted by phone to arrange a convenient appointment, or by post if not contactable by phone. Those who fail to attend the clinic on the first appointment are given a second appointment to attend, and all patients were prospectively registered in the single point of access database. The medical notes of the non-attendees were reviewed to determine the reason for the non-attendance. If there was no relevant record in the medical notes, the general practitioners or the patients themselves were contacted by phone. Death certificates were reviewed where appropriate. Any relevant imaging, including computed tomography of the head or carotid Doppler ultrasound, was also reviewed.
In all, 1460 patients were referred during the 27 months study period and 121 failed to attend in spite of being sent two appointment. The median waiting time from referral to appointment was 17 days (range 0 to 96); 47.6% of patients were seen within two weeks of referral. The mean age of the non-attendees was 71 years (29 to 93); 44 were male and 77 female. Risk factors for TIA or minor stroke included atrial fibrillation (5.7%), hypertension (14%), diabetes (5.7%), and hypercholesterolaemia (11.5%). Reasons for non-attendance included 39 (32%) who had a stroke requiring admission to hospital, of which 27 (69%) occurred during the first three days after referral (fig 1). Thirteen of the 39 strokes (33%) were fatal. CT showed evidence of infarction in 31 (80%), intracranial haemorrhage in 2 (5%), and was normal or not undertaken in 6 (15%). Seventeen patients (44%) had carotid Doppler ultrasound, and of these, four had stenosis exceeding 50%.
Patients with TIA are at significant short term risk of stroke, previously reported as ranging from 4% to 8% in the first month.3 Therefore the National Service Framework and National Clinical Guidelines for Stroke recommended the setting up of rapid access neurovascular clinics in which patients should be seen within 14 days of referral. In a study of patients presenting to an emergency department—almost all of whom were enrolled within 24 hours of the TIA—the reported stroke risk was 5% in the first two days.4 The Oxfordshire community stroke project (OCSP) prospectively followed a population of patients presenting to their primary care provider with a TIA or completed stroke reported a 4.4% risk of stroke in the first month following a recent TIA.5 In the subsequent OCSP study, which redefined the index event, the authors suggested that the risk was much higher than the initial estimate, lying at 8.6% and 12.0% at seven and 30 days, respectively.6 In our present review, 32% of patients who failed to attend the clinic did so because they had a stroke requiring hospital admission in the interval between seeing their general practitioners and the clinic appointment; 27 occurred in the first three days after referral, suggesting that the recommendation in the National Clinical Guidelines for Stroke about the timing of referrals to neurovascular clinics may need revision.
Our study may be criticised on the grounds that information about the timing of the index event was not included; however, we regard this report as being a pragmatic view of what is happening in reality. A rapid access neurovascular service is unlikely to be effective in preventing stroke unless patients can be seen and treated on the same day that they present. This study highlights the need for urgent evaluation and treatment of those at risk of stroke, ideally on the same day as the index event. Studies are required to determine the most effective intervention. The challenge for stroke physicians is to test the effects of combination treatment comprising combined antiplatelet therapy, a cholesterol lowering drug, and blood pressure lowering agents given as soon as possible after the index event to reduce the risk of immediate stroke.
Competing interests: none declared