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Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study.

ABSTRACT: OBJECTIVES:There is a lack of knowledge regarding post-discharge hospitalisation utilisation after transient ischaemic attack (TIA) in China. The aim of this study is to quantify rehospitalisation use in survivors of TIA compared with their own previous hospital use and matched survivors of stroke. DESIGN:Nested case-control study of electronic medical records datasets. SETTING:958 hospitals in Henan, China, from July 2012 to December 2015. PARTICIPANTS:In total, 4823 survivors of stroke were matched to the TIA cohort (average age: 64.5 years; proportion of men: 48.4%) at a 1:1 ratio. All subjects with an onset of stroke/TIA were recorded with a 1-year look-back and follow-up. OUTCOME MEASURES:Adjusted difference-in-differences (DID) values in 1-year hospital lengths of stay (LOSs) and readmission within 7, 30 and 90 days. RESULTS:There was an increase in hospital admissions in survivors of TIA in the year after the index hospitalisation compared with the prior year. Of the 2449 rehospitalisation events that occurred during the first year after TIA, stroke (20.6%) was the most common reason for rehospitalisation. There was no difference in the stroke-specific readmission rates between the TIA and stroke cohorts (p=0.198). The TIA cohort had fewer readmissions within 30 days and 90 days after all-cause discharge compared with the controls. The corresponding covariate-adjusted DID values were -3.5 percentage points (95%?CI -5.3 to -1.8) and -4.5 (95% CI -6.5 to -2.4), respectively. A similar trend was observed in the 1-year LOS. In the stratified analysis, the DID reductions were not significant in patients with more comorbidities or in rural patients. CONCLUSIONS:Compared with survivors of stroke, survivors of TIA use fewer hospital resources up to 1?year post-discharge. Greater attention to TIAs among patients with more comorbidities and rural patients may provide an opportunity to reduce hospital use.

SUBMITTER: Li S

PROVIDER: S-EPMC6624025 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study.

Li Sangsang S Tian Qingfeng Q Fan Junxing J Shi Zhan Z Guo Bingxin B Chen Huanan H Li Yapeng Y Shi Songhe S

BMJ open 20190709 7

<h4>Objectives</h4>There is a lack of knowledge regarding post-discharge hospitalisation utilisation after transient ischaemic attack (TIA) in China. The aim of this study is to quantify rehospitalisation use in survivors of TIA compared with their own previous hospital use and matched survivors of stroke.<h4>Design</h4>Nested case-control study of electronic medical records datasets.<h4>Setting</h4>958 hospitals in Henan, China, from July 2012 to December 2015.<h4>Participants</h4>In total, 482 ...[more]

PMID: 31292173

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Project description:BackgroundAn increasing body of evidence suggests that inflammation plays a key role in stroke, in particular stroke of atherosclerotic origin. Anti-inflammatory medications are a widely heterogeneous group of drugs that are used to suppress the innate inflammatory pathway and thus prevent persistent or recurrent inflammation. Anti-inflammatory agents have the potential to stabilise atherosclerotic plaques by impeding the inflammatory pathway. By targeting specific cytokines, the inflammatory pathway may be interrupted at various stages.ObjectivesTo assess the benefits and harms of anti-inflammatory medications plus standard care versus standard care with or without placebo for prevention of vascular events (stroke, myocardial infarction (MI), non-fatal cardiac arrest, unstable angina requiring revascularisation, vascular death) and all-cause mortality in people with a prior history of ischaemic stroke or transient ischaemic attack (TIA).Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL; last searched 29 May 2019); MEDLINE (1948 to 29 May 2019); Embase (1980 to 29 May 2019); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 29 May 2019); and Scopus (1995 to 29 May 2019). In an effort to identify additional published, unpublished, and ongoing trials, we searched several grey literature sources (last searched 30 May 2019). We incorporated all identified studies into the results section. We applied no restrictions with respect to language, date of publication, or study setting.Selection criteriaWe considered randomised controlled trials (RCTs) and cluster-randomised controlled trials that evaluated anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA.Data collection and analysisTwo review authors independently assessed for inclusion titles and abstracts of studies identified by the search. Two review authors independently reviewed full-text articles for inclusion in this review. We planned to assess risk of bias and to apply the GRADE method.Main resultsWe identified no studies that met the inclusion criteria.Authors' conclusionsThere is currently a paucity of evidence on the use of anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA. RCTs are needed to assess whether use of anti-inflammatory medications in this setting is beneficial.

Project description:The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Project description:Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Dataset Information

Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study.

Publications

Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study.

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