Outpatient stroke prevention clinics may be as effective as organized inpatient care

Outpatient stroke prevention clinics may be as effective as organized inpatient care in patients who have had an ischemic stroke or transient ischemic attack (TIA), according to a new study.

Although research has shown that organized inpatient care for stroke decreases morbidity and mortality across age, stroke severity, and stroke subtype, data are limited on the effectiveness of outpatient care models, such as stroke prevention clinics. Researchers in Ontario, Canada, performed a retrospective cohort study to determine the effectiveness of outpatient stroke prevention clinics in preventing mortality and repeated hospital admission in patients with an initial hospital admission for stroke or TIA.

Included patients were those seen in the emergency department or admitted to the hospital for TIA or ischemic stroke between July 1, 2003 and March 31, 2008. Data were obtained from government databases. The primary outcome measure was all-cause mortality one year after an index hospital visit for stroke or TIA. Secondary outcome measures included readmission for stroke or TIA one year after the index visit, along with receipt of neuroimaging, carotid imaging and carotid endarterectomy, prescription of antihypertensive and lipid-lowering drugs, and number of physician visits within six months. Study results were published online Sept. 15 by Stroke.

Data were available for 16,468 patients with ischemic stroke or TIA. Of these, 7,700 (47%) were referred to a stroke prevention clinic for follow-up care. At one year after index admission, mortality rates were lower in patients referred to stroke prevention centers than in those who were not (5.9% vs. 15.5%; P<0.001). This finding remained consistent after adjustment for age, sex, ethnicity, income, comorbidities, stroke symptoms and severity, use of thrombolysis, stroke unit care, discharge location and functional status when discharged (adjusted hazard ratio, 0.67; 95% CI, 0.60 to 0.75). After propensity matching, survival analysis indicated a reduction of 26% in one-year mortality among those referred to outpatient clinics (hazard ratio, 0.74; 95% CI, 0.65 to 0.84). One-year rates of hospital readmissions or emergency department visits, however, did not differ between groups.

Patients referred to stroke prevention clinics had more physician visits, were more likely to receive antiplatelet and lipid-lowering therapy, and were more likely to have magnetic resonance and carotid imaging, echocardiography, and Holter monitoring, but were less likely to undergo carotid revascularization. Rates of computed tomography, antihypertensive therapy and warfarin therapy for atrial fibrillation did not differ significantly between groups.

The authors acknowledged that their study might be affected by residual confounding because of its observational design. They also noted that they were unable to determine whether all patients who were referred to outpatient stroke prevention clinics were actually seen there, and that they could not determine the specific care provided at the clinics.

However, they concluded that organized outpatient care after stroke improves patient care and helps significantly reduce mortality. They called for future research to examine specific interventions used at outpatient clinics and determine which are most effective. Cost-effectiveness and patient satisfaction and adherence should also be considered in future studies, they wrote.