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. 2023 May 16;100(20):e2093-e2102.
doi: 10.1212/WNL.0000000000207201. Epub 2023 Mar 28.

Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention

Thomas J Jeerakathil  1 , Amy Ying Xin Yu  2 , Philip M C Choi  2 , Shoufan Fang  2 , Ashfaq Shuaib  2 , Sumit R Majumdar  2 , Andrew M Demchuk  2 , Kenneth Butcher  2 , Tim J Watson  2 , Naeem Dean  2 , Deb Gordon  2 , Michael D Hill  2 , Cathy Edmond  2 , Shelagh B Coutts  2 ; ASPIRE Investigators
Collaborators, Affiliations

Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention

Thomas J Jeerakathil et al. Neurology. .

Abstract

Background and objectives: Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA.

Methods: In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model.

Results: We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention.

Discussion: The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded.

Classification of evidence: This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.

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Conflict of interest statement

T.J. Jeerakathil received funding for this project from the Heart and Stroke Foundation of Canada, the Canadian Institutes for Health Research, and the Canadian Stroke Network. The TIA hotline component was funded by Alberta Health Services. A.Y.X. Yu received fellowship funding from Alberta Innovates Health Solutions. P.M.C. Choi, S. Fang, A. Shuaib, S.R. Majumdar, A.M. Demchuk, K.S. Butcher, T.J. Watson, N. Dean, D. Gordon, M.D. Hill, and C. Edmond reports no disclosures relevant to the manuscript. S.B. Coutts received funding for this project from the Heart and Stroke Foundation of Canada, the Canadian Institutes for Health Research, and the Canadian Stroke Network. The TIA hotline component was funded by Alberta Health Services. S.B> Coutts received salary support from the Alberta Innovates-Health solutions and the Heart and Stroke Foundation of Canada's Distinguished Clinician Scientist award, supported in partnership with the Canadian Institute of Health Research (CIHR), Institute of Circulatory and Respiratory Health, and AstraZeneca Canada Inc. Go to Neurology.org/N for full disclosures.

Figures

Figure 1
Figure 1. The ASPIRE Algorithm
ABCD2 score assigns points for age older than 60 years (+1); blood pressure ≥140/90 mm Hg; clinical deficits (+2 points for motor or +1 point for speech); diabetes (+1); and duration of symptoms (+1 point for 10–59 minutes or +2 points for ≥60 minutes). ASPIRE = Alberta Stroke Prevention in TIAs and Mild Strokes; TIA = transient ischemic attack.
Figure 2
Figure 2. Interrupted Time Series Autoregression Best-Fit Lines and 95% Confidence Limits for Recurrent Stroke and Composite Outcomes at 90 Days
X-axis unit: ASPIRE Quarter. The 15-month blackout period for implementation extended from March 2009 to June 2010. We were not able to demonstrate a significantly different slope or step change in the postimplementation period compared with that in the preimplementation period. ASPIRE = Alberta Stroke Prevention in TIAs and Mild Strokes; TIA = transient ischemic attack.
See this image and copyright information in PMC

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