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Research paper
Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study
  1. Nicola L M Paul1,
  2. Silvia Koton2,
  3. Michela Simoni1,
  4. Olivia C Geraghty1,
  5. Ramon Luengo-Fernandez3,
  6. Peter M Rothwell1
  1. 1Nuffield Department of Clinical Neurosciences, Stroke Prevention Research Unit,  John Radcliffe Hospital, Oxford, UK
  2. 2Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
  3. 3Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK
  1. Correspondence to Professor Peter M Rothwell, Nuffield Department of Clinical Neurosciences, Stroke Prevention Research Unit, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK; peter.rothwell{at}clneuro.ox.ac.uk

Abstract

Background Outpatient management safely and effectively prevents early recurrent stroke after transient ischaemic attack (TIA), but this approach may not be safe in patients with acute minor stroke.

Objective To study outcomes of clinic and hospital-referred patients with TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) in a prospective, population-based study (Oxford Vascular Study).

Results Of 845 patients with TIA/stroke, 587 (69%) were referred directly to outpatient clinics and 258 (31%) directly to inpatient services. Of the 250 clinic-referred minor strokes (mean age 72.7 years), 237 (95%) were investigated, treated and discharged on the same day, of whom 16 (6.8%) were subsequently admitted to hospital within 30 days for recurrent stroke (n=6), sepsis (n=3), falls (n=3), bleeding (n=2), angina (n=1) and nursing care (n=1). The 150 patients (mean age 74.8 years) with minor stroke referred directly to hospital (median length-of-stay 9 days) had a similar 30-day readmission rate (9/150; 6.3%; p=0.83) after initial discharge and a similar 30-day risk of recurrent stroke (9/237 in clinic patients vs 8/150, OR=0.70, 0.27–1.80, p=0.61). Rates of prescription of secondary prevention medication after initial clinic/hospital discharge were higher in clinic-referred than in hospital-referred patients for antiplatelets/anticoagulants (p<0.05) and lipid-lowering agents (p<0.001) and were maintained at 1-year follow-up. The mean (SD) secondary care cost was £8323 (13 133) for hospital-referred minor stroke versus £743 (1794) for clinic-referred cases.

Conclusion Outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Rates of early hospital admission and recurrent stroke were low and uptake and maintenance of secondary prevention was high.

  • minor stroke
  • transient ischaemic attack
  • outpatient clinic

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