A specialist-driven, rapid access outpatient clinic for patients with acute minor stroke/TIA delivers shorter acute hospital stays, lower readmission rates, and better quality care than hospitalisation in stroke units.
A Danish study compared outcomes in 1,000 consecutive patients to the acute outpatient clinic with an historic cohort from the same hospital and a contemporary cohort of minor stroke /TIA patients admitted to a comparable hospital.
In the outpatient model, all patients bypassed the ED. Ambulance or GPs called a 24/7 hotline to arrange evaluation by a stroke specialist. Patients were either seen in the outpatient clinic during its opening hours (8am to 6pm; seven days per week) or admitted to the stroke unit.
The study found almost half of the patients had a neurovascular diagnosis (47.4%) including stroke and TIA.
Only 23.5% of patients seen at the outpatient clinic were eventually admitted to hospital. Most low risk patients – 43.7% of those with stroke and 70.8% of those with TIA – were able to be sent home straight from the outpatient clinic.
Stroke patients first seen at the clinic had a shorter risk-adjusted length of acute hospital stay than the historic stroke cohort (median 1 vs 3 days) and the contemporary cohort (1 v 4 days).
The length of total stay including stroke rehabilitation was also shorter in the stroke patients seen initially in the outpatient clinic compared to the historic stroke controls ( 1 v 4 days).
All-cause bed days within the first year were fewer in the outpatient group than controls (2 v 6 days in both historic and contemporary controls) and readmission rates within the first 30 days after the initial hospital stay were lower (3.2% v 11.6% and 11.3%).
Mortality rates were similar and low in all groups, both at day 30 (0% vs 0.5% and 0%) and day 365 (2.6% vs 5.2% and 5.7%).
In patients with TIA, the acute and total hospital stays were significantly shorter in the outpatient group than in the matched contemporary cohort of TIA patients (0.5 days v 2 days for both outcomes).
Mortality rates at day 30 (0% v 0%) and day 365 (2.0% v 5.9%) were also comparable in the two TIA cohorts.
“This prospective cohort study of patients seen in an outpatient clinic for acute minor stroke and TIA using subsequent admission of high-risk patients shows that these patients have a shorter hospital stay, lower rate of readmissions at 30 days, and higher quality of care than patients in matched historic and contemporary cohorts without a similar outpatient service.”
Despite its non-randomised design, the study said the model of care appeared safe and effective.
An editorial in Neurology, led by Professor Anna Ranta of the University of Otago (NZ), said the findings made a strong case for initial evaluation of all patients with TIA/minor stroke in a specialist outpatient unit instead of universal admission to a stroke unit.
“The service model may cost less per patient, free up hospital bed–days for patients with more severe stroke, and reduce stroke-related readmissions (>24-hour hospital stay after the first admission).”
“Certainly, the lack of difference in mortality and early stroke recurrence rates comparable to other published data suggests no harm from this service model.”
“Clinical trial comparison of outpatient vs inpatient TIA and minor stroke management would be an excellent focus of future research in this area.”