Urgent ambulant care model for suspected TIA reduced hospital use and costs, but at what price?

Abstract

Background Transferring TIA management from hospital to outpatient settings may offer more cost-effective stroke prevention.

Aims To assess the effects of an ambulatory TIA care pathway implemented across a health service on: overnight admission, total hospital length of stay (LOS), costs and 90-day stroke.

Methods A co-designed pathway was implemented across Sunshine Coast Health Service (4 hospitals; 2 rural, 10,000 km2) that included emergency department (ED) assessment and treatment protocols followed by review in a medical day unit, or telemedicine clinic in one rural hospital. Interrupted time series analysis was used on linked hospital administrative datasets for all ED TIA diagnosis 5 years before and 2 years after a censored 6-month implementation period (2015).

Results There were 1476 presentations before and 564 after pathway implementation. Overnight admissions and LOS were declining pre-implementation. Compared with pre-implementation predictions, overnight admissions dropped 12.4% (95%CI −5.0, −19.7) and LOS fell 6 hours (95%CI 1.5, 10.4) in the first quarter post-implementation; then declined further reaching: admissions 32%, LOS 6.1hrs at study end. Median hospital costs fell AUD683 immediately after implementation. Ambulant review occurred in 36% at median 5 days (IQR 3, 9), including 19/87 (22%) telemedicine reviews. Pathway adherence was incomplete: 29% were neither admitted nor had ambulant review. Recurrent stroke began at 0.9/100 presentations, declined non-significantly pre-pathway, increased by 1.3/100 presentations (95%CI 0.6, 2.1) during implementation, then declined again to 0.9/100.

Conclusion An ambulant care pathway decreased hospital use and costs, but recurrent stroke increased initially. Ensuring early follow up for all is essential.