Management of transient ischemic attacks diagnosed by early-career general practitioners: A cross-sectional study

Abstract

Background

Transient ischemic attack incurs a risk of recurrent stroke that can be dramatically reduced by urgent guideline-recommended management at the point of first medical contact.

Aims

This study describes the prevalence and associations of new transient ischemic attack presentations to general practice registrars and the management undertaken.

Methods

A cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. General practice registrars from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of their three six-month training terms. The proportion of problems managed being new transient ischemic attacks and proportion of transient ischemic attacks with guideline-recommended management were calculated. Univariate and multivariable logistic regression established associations of patient, registrar, and practice factors with a problem being a new transient ischemic attack.

Results

A total 1331 general practice registrars contributed data (response rate 95.8%). Of the 250,625 problems, there were 65 new transient ischemic attacks diagnosed (0.03% [95% confidence interval: 0.02–0.03%]). General practice registrars were more likely to seek help, generate learning goals, and spend more time for a new transient ischemic attack compared to other problems. Compliance with management guidelines was modest: 15.4% ordered brain and arterial imaging, 36.9% prescribed antiplatelet medication, and 3.1% prescribed antihypertensive medication.

Conclusions

Transient ischemic attack is a very infrequent presentation for general practice registrars, giving little clinical opportunity to reinforce training program education regarding guideline-recommended management. General practice registrars found transient ischemic attacks challenging and management was not ideal. Since most transient ischemic attacks first present to general practice and urgent management is essential, an enhanced model of care utilizing rapid access to specialist transient ischemic attack support and follow-up could improve guideline compliance.

Keywords

General practice neurology cerebrovascular disorders transient ischemic attack stroke treatment telemedicine

Get full access to this article

View all access options for this article.

References

Giles

Rothwell

. Transient ischaemic attack: clinical relevance, risk prediction and urgency of secondary prevention. Curr Opin Neurol 2009; 22: 46–53.

Johnston

Gress

Browner

Sidney

. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000; 284: 2901–2906.

Australian Institute of Health and Welfare 2012. Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW, 2012.

Deloitte Access Economics. The Economic Impact of Stroke in Australia. National Sroke Foundation, 13 March 2013. Canberra, Australia, 2013.

Rothwell

Giles

Chandratheva

et al.

Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370: 1432–1442.

NICE Pathways. TIA: assessment, early management and imaging. National Institute for Health and Care Excellence, http://pathways.nice.org.uk/pathways/stroke#path=view%3A/pathways/stroke/tia-assessment-early-management-and-imaging.xml&content=view-index (2015, accessed 9 September 2015).

Easton

Saver

Albers

et al.

Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. Stroke 2009; 40: 2276–2293.

National Stroke Foundation. Clinical guidelines for stroke management. Melbourne, Australia. 2010.

Clarey

Lasserson

Levi

et al.

Absolute cardiovascular risk and GP decision making in TIA and minor stroke. Fam Pract 2014; 31: 664–669.

10.

Leung

Hamilton-Bruce

Price

Koblar

. Transient ischaemic attack (TIA) knowledge in general practice: a cross-sectional study of Western Adelaide general practitioners. BMC Res Notes 2012; 5: 278.

11.

Davey AR, Lasserson DS, Levi CR and Magin PJ. Managing transient ischaemic attacks in Australia: a qualitative study. Family Pract 2017; 34: 606–611.

12.

Department of Health. Australian General Practice Training. Australian Government, http://www.agpt.com.au/ (2016, accessed 1 May 2016).

13.

Morgan

Henderson

Tapley

et al.

Problems managed by Australian general practice trainees: results from the ReCEnT (Registrar Clinical Encounters in Training) study. Educ Prim Care 2014; 25: 140–148.

14.

Bonney

Phillipson

Reis

Jones

Iverson

. Patients’ attitudes to general practice registrars: a review of the literature. Educ Prim Care 2009; 20: 371–378.

15.

Sprigg

Machili

Otter

Wilson

Robinson

. A systematic review of delays in seeking medical attention after transient ischaemic attack. J Neurol Neurosurg Psychiat 2009; 80: 871–875.

16.

Morgan

Magin

Henderson

et al.

Study protocol: the registrar clinical encounters in training (ReCEnT) study. BMC Family Pract 2012; 13: 50. doi: 10.1186/1471-2296-13-50.

17.

World Health Organization. International classification of primary care. 2nd ed. (ICPC-2), http://www.who.int/classifications/icd/adaptations/icpc2/en/ (2003, accessed 28 October 2015).

18.

Australian Bureau of Statistics. 1216.0—Australian standard geographical classification (ASGC)—2006, http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/1AE106C101420508CA2571A900170741 (2006, accessed 28 October 2015).

19.

Australian Bureau of Statistics. 2039.0—Information paper: an introduction to socio-economic indexes of areas (SEIFA), 2006, http://www.abs.gov.au/ausstats/abs@.nsf/mf/2039.0/(2006, accessed 28 October 2015).

20.

WHO Collaborating Centre for Drug Statistics Methodology. Anatomical therapeutic chemical (ATC) classification system. Structure and principles, http://www.whocc.no/atc/structure_and_principles/ (accessed 28 October 2015).

21.

Charles

Pan

Miller

. TIAs—management in general practice. Aust Fam Phys 2010; 39: 813.

22.

Maddison

. Neurology training in the United Kingdom: a diagnostic analysis of over 5000 patients. J Neurol 2005; 252: 605–607.

23.

Ferro

Falcao

Rodrigues

et al.

Diagnosis of transient ischemic attack by the nonneurologist: a validation study. Stroke 1996; 27: 2225–2229.

24.

Castle

Mlynash

Lee

et al.

Agreement regarding diagnosis of transient ischemic attack fairly low among stroke-trained neurologists. Stroke 2010; 41: 1367–1370.

25.

Bonevski

Magin

Horton

Foster

Girgis

. Trialing two recruitment strategies for improving response rates in general practitioner surveys: mission impossible. Aust Fam Phys 2011; 40: 427–430.

26.

Amarenco

Lavallée

Labreuche

et al.

One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med 2016; 374: 1533–1542.

27.

Schwamm

Holloway

Amarenco

et al.

A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009; 40: 26162634.