More than two-thirds of patients who are discharged from the emergency department after suffering transient ischemic attacks (TIAs) do not complete recommended imaging within 30 days post-discharge, according to a study presented at RSNA 2021.
Timpone
TIAs, often referred to as mini strokes, are brief episodes that occur when parts of the brain are temporarily starved of blood. Symptoms are similar to those of a stroke, but they don’t last as long. TIAs are considered a warning sign for future strokes.
Guidelines recommend brain imaging with MRI or CT, preferably within 48 hours of symptom onset. Additionally, it’s recommended that all patients should have screening of the blood vessels in their head and neck with either CTA, MRA or carotid ultrasound within a similar time frame.
Researchers led by Vincent Timpone, MD, assistant professor at University of Colorado School of Medicine in Aurora, previously demonstrated that a majority of TIA patients discharged from the emergency department without hospital admission do not complete a recommended TIA imaging workup during their emergency department encounter. For the new study, they went a step further.
“The old database we used was based only on emergency department information, so there was no way of knowing what happened to those patients when they were discharged,” Dr. Timpone said. “The purpose of this study was to see what happened to those patients after they were discharged.”
The researchers analyzed more than 6,300 TIA encounters from a Medicare database. Of those, 3,804 (60%) had a complete TIA imaging workup during their emergency department encounter.
Of the 2,542 of patients discharged from EDs with incomplete imaging, only 761 (30%) had completed imaging during the subsequent 30-days post-emergency department discharge.
“This study shows that if you discharge a patient with incomplete workup, there’s a high likelihood they’re not going to get that workup as an outpatient,” Dr. Timpone said. “Seventy percent of patients in our study were lost to follow-up.”
It is unknown how many of these incompletely imaged patients may have had a stroke or face a significant risk of one in the future.
“Theoretically, if you don’t do a complete imaging workup you might miss a stroke that’s occurred, and if you don’t screen the blood vessels you might not recognize vascular risk factors that can lead to future strokes,” Dr. Timpone said. “It’s important to complete the imaging work-up, so that potentially modifiable risk factors for stroke will be recognized and treated appropriately.”
Barriers to Follow Up
There are likely a variety of reasons for the lack of imaging follow-up, Dr. Timpone said. Access to outpatient imaging might be limited in some areas. In addition, clinicians and patients may gain a false sense of security based solely on brain imaging results, unaware that vascular imaging is needed to identify those lesions that place them at an increased risk for future strokes.
The study found that the odds of incomplete TIA imaging workup at 30-days post emergency department discharge were increased in Black patients and older patients. Previous research has shown that these groups are adversely affected by various health care disparities. The reasons for such disparities are uncertain, but may result from personal or facility barriers to accessing care, living in proximity to lower-performing hospitals, implicit biases in the system, and general distrust of the health care system.
“It’s important for health care providers to be aware of these deficiencies in the workup of TIA and to recognize which patients are most likely not to receive the standard of care,” Dr. Timpone said. “Providers should develop systems to better follow up on these patients when discharged and facilitate timely imaging.”
The researchers plan to follow up the study by comparing patients who were incompletely imaged with those that were and see if the incomplete imaging is a risk factor for future stroke.
Access the presentation, “Lost to Follow Up: A Nationwide Analysis of Transient Ischemic Attack Patients Discharged From ED With Incomplete Imaging Workup,” (SSNR06) on demand at Meeting.RSNA.org.
