Barbara J Homoya1,2, Teresa M Damush3,4,5,6, Jason J Sico7,8, Edward J Miech3,4,5,6,9, Gregory W Arling3,6,10, Laura J Myers3,4,5, Jared B Ferguson3,4, Michael S Phipps11, Eric M Cheng12, Dawn M Bravata3,4,5,6,13. 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.
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.
BACKGROUND:Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIApatients 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 TIApatients 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 TIApatients." 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 TIApatients 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 TIApatients and delivery of secondary prevention strategies.
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