Analysis of six months' referrals to a "one-stop" neurovascular clinic in a district general hospital: implications for purchasers of a stroke service.

OBJECTIVE: To determine the effectiveness of a "one-stop" neurovascular clinic (NVC) in guiding the diagnosis and investigation of patients suffering a mild stroke or transient ischaemic attack (TIA).
DESIGN: Six months' survey of the activity of a new neurovascular clinic (NVC).
SETTING: Borders region of Scotland.
SUBJECTS: Patients referred with a suspected diagnosis of stroke or TIA.
RESULTS: The clinic served 23 general practices and a population of 106,000. Over a 6 month period 128 patients were referred; 93% of patients were referred by general practitioners, 5% by consultant physicians and 2% from wards in the Borders General Hospital. Most patients were independent prior to the presenting event and had minimal disability on presentation to the clinic. Patients were seen within 48 hours of referral in the majority of cases and all within five working days. However, only 52% were seen within two weeks of the onset of their symptoms. Only 50% of patients were shown to have sustained a stroke or TIA. A variety of other diagnoses mimicked vascular events including epilepsy, migraine, cranial nerve palsies and cerebral tumour. The stroke-related group differed significantly in age (P = 0.003) and in the number of patients already on aspirin (P = 0.010) but not in any other risk factor. CT scan and carotid doppler examination were considered necessary in only 47% and 24% respectively of referred patients. Only five stroke-related patients and one non-stroke-related patient needed further input from physiotherapy, occupational therapy or speech therapy. Over 90% of patients were discharged home. Patient and general practitioner satisfaction with the service received were rated at 9 (0 = very poor; 10 = excellent).
CONCLUSION: Applying evidence-based medicine to patients attending a "one-stop" neurovascular clinic with minor stroke and/or transient ischaemic attack resulted in an efficient delivery of appropriate investigations and therapy to this group of patients. The NVC prevented unnecessary requests for both CT scanning and carotid doppler examination, which are valuable resources, and may have prevented admissions to hospital. Patients were anxious about their symptoms and appreciated being seen quickly and a diagnosis made. We would recommend that these clinics be set up as part of the stroke service in all district general hospitals.