Multicenter Study

. 2019 Sep;34(9):1715-1723.

doi: 10.1007/s11606-018-4735-9. Epub 2018 Nov 27.

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Barbara J Homoya^{1

2}, Teresa M Damush^{3

4

5

6}, Jason J Sico^{7

8}, Edward J Miech^{3

4

5

6

9}, Gregory W Arling^{3

6

10}, Laura J Myers^{3

4

5}, Jared B Ferguson^{3

4}, Michael S Phipps¹¹, Eric M Cheng¹², Dawn M Bravata^{3

4

5

6

13}

Affiliations

¹ Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. Barbara.Homoya@va.gov.
² VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA. Barbara.Homoya@va.gov.
³ Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
⁴ VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.
⁵ Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
⁶ Regenstrief Institute, Indianapolis, IN, USA.
⁷ Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA.
⁸ Departments of Internal Medicine and Neurology and Center for NeuroEpidemiological and Clinical Research, Yale School of Medicine, New Haven, CT, USA.
⁹ Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁰ Purdue University School of Nursing, West Lafayette, IN, USA.
¹¹ Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
¹² Department of Neurology, Los Angeles School of Medicine, University of California, Los Angeles, CA, USA.
¹³ Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.

PMID: 30484102
PMCID: PMC6712185
DOI: 10.1007/s11606-018-4735-9

Multicenter Study

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Barbara J Homoya et al. J Gen Intern Med. 2019 Sep.

. 2019 Sep;34(9):1715-1723.

doi: 10.1007/s11606-018-4735-9. Epub 2018 Nov 27.

Authors

Affiliations

¹ Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. Barbara.Homoya@va.gov.
² VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA. Barbara.Homoya@va.gov.
³ Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
⁴ VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.
⁵ Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
⁶ Regenstrief Institute, Indianapolis, IN, USA.
⁷ Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA.
⁸ Departments of Internal Medicine and Neurology and Center for NeuroEpidemiological and Clinical Research, Yale School of Medicine, New Haven, CT, USA.
⁹ Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁰ Purdue University School of Nursing, West Lafayette, IN, USA.
¹¹ Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
¹² Department of Neurology, Los Angeles School of Medicine, University of California, Los Angeles, CA, USA.
¹³ Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.

PMID: 30484102
PMCID: PMC6712185
DOI: 10.1007/s11606-018-4735-9

Abstract

Background: Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably.

Objectives: We sought to identify factors associated with the decision to admit patents with TIA.

Design: We conducted a secondary analysis of a prior study's data including semi-structured interviews, administrative data, and chart review.

Participants: We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011.

Approach: For the qualitative data, we focused on interviewees' responses to the prompt: "Tell me what influences you in the decision to or not to admit TIA patients." We used administrative data to identify admission rates and chart review data to identify ABCD² scores (a tool to classify stroke risk after TIA).

Key results: Providers' decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD² score, and concerns about facilities' ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD² scores and related guidelines in admission decision-making.

Conclusions: Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Keywords: admission; transient ischemic attack.

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Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

**Figure 1**
Acute TIA Quality Processes of Care.

See this image and copyright information in PMC

Comment in

Capsule Commentary on Homoya et al., Uncertainty as a Key Influence in the Decision to Admit Patients with Transient Ischemic Attack.
Amos Bailey F. Amos Bailey F. J Gen Intern Med. 2019 Sep;34(9):1849. doi: 10.1007/s11606-018-4802-2. J Gen Intern Med. 2019. PMID: 31286401 Free PMC article. No abstract available.

Cited by

Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack.
Damush TM, Miech EJ, Rattray NA, Homoya B, Penney LS, Cheatham A, Baird S, Myers J, Austin C, Myers LJ, Perkins AJ, Zhang Y, Giacherio B, Kumar M, Murphy LD, Sico JJ, Bravata DM. Damush TM, et al. J Gen Intern Med. 2021 Feb;36(2):322-332. doi: 10.1007/s11606-020-06100-w. Epub 2020 Nov 3. J Gen Intern Med. 2021. PMID: 33145694 Free PMC article. Clinical Trial.
Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration.
Arling G, Sico JJ, Reeves MJ, Myers L, Baye F, Bravata DM. Arling G, et al. BMJ Open Qual. 2019 Dec 4;8(4):e000641. doi: 10.1136/bmjoq-2019-000641. eCollection 2019. BMJ Open Qual. 2019. PMID: 31909209 Free PMC article.
Capsule Commentary on Homoya et al., Uncertainty as a Key Influence in the Decision to Admit Patients with Transient Ischemic Attack.
Amos Bailey F. Amos Bailey F. J Gen Intern Med. 2019 Sep;34(9):1849. doi: 10.1007/s11606-018-4802-2. J Gen Intern Med. 2019. PMID: 31286401 Free PMC article. No abstract available.
Qualitative analysis of disposition decision making for patients referred for admission from the emergency department without definite medical acuity.
Trinh T, Elfergani A, Bann M. Trinh T, et al. BMJ Open. 2021 Jul 14;11(7):e046598. doi: 10.1136/bmjopen-2020-046598. BMJ Open. 2021. PMID: 34261682 Free PMC article.
Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial.
Bravata DM, Myers LJ, Perkins AJ, Zhang Y, Miech EJ, Rattray NA, Penney LS, Levine D, Sico JJ, Cheng EM, Damush TM. Bravata DM, et al. JAMA Netw Open. 2020 Sep 1;3(9):e2015920. doi: 10.1001/jamanetworkopen.2020.15920. JAMA Netw Open. 2020. PMID: 32897372 Free PMC article.

See all "Cited by" articles

References

1. Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–72. doi: 10.1016/s1474-4422(07)70274-0. - DOI - PubMed
1. Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med. 2007;167(22):2417–22. doi: 10.1001/archinte.167.22.2417. - DOI - PubMed
1. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369(1):11–9. doi: 10.1056/NEJMoa1215340. - DOI - PubMed
1. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284(22):2901–6. doi: 10.1001/jama.284.22.2901. - DOI - PubMed
1. Kelly AG, Rothwell PM. Evaluating patients with TIA: to hospitalize or not to hospitalize? Neurology. 2011;77(24):2078–9. doi: 10.1212/WNL.0b013e31824004fe. - DOI - PubMed

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Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

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Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

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