VIEWS & REVIEWS

Transient ischemic attack service provision

A review of available service models

Annemarei Ranta, PhD,

MD, FRACP
P. Alan Barber, PhD,
MBChB, FRACP

Correspondence to
Dr. Ranta:
anna.ranta@otago.ac.nz

ABSTRACT

TIAs are predictors of high risk of subsequent stroke and require urgent intervention to maximize
secondary prevention and minimize adverse health outcomes. TIA patients are often admitted to
the hospital to facilitate rapid investigation and comprehensive management. However, over the
last 2 decades, alternative service models have emerged in an effort to optimize health resource
utilization without compromising patient outcomes. This article reviews recommended interventions and then discusses the inpatient and 6 alternative TIA service models to help modern stroke
services determine the model best suited to their local health service environment. Neurology
2016;86:947953
GLOSSARY
ARR 5 absolute risk reduction; CI 5 confidence interval; GP 5 general practitioner; IQR 5 interquartile range; M3T 5 Monash
Transient Ischemic Attack Triaging Treatment; NNT 5 number needed to treat; OR 5 odds ratio; RRR 5 relative risk
reduction.

TIAs are predictors of high risk of subsequent stroke.1 TIA precedes approximately 25% of
ischemic strokes,2 and up to 10.5% to 18.2% of TIA patients go on to have a stroke within 90
days.35 TIA also signals increased risk of other complications such as recurrent TIA (12.7%),
cardiovascular hospitalization (2.6%), and death (2.6%).3 The risk of stroke is greatest in the
first few hours and days after a TIA, and stroke rates of as high as 8.1% within 48 hours of TIA
have been reported in some patients.6,7 The high risk of disabling and fatal stroke within a few
days of a TIA is the basis for clinical guidelines recommending urgent intervention.8,9
AVAILABLE SECONDARY PREVENTIVE MEASURES The key intervention following TIA shown to reduce
subsequent stroke risk is urgent (between ,24 hours and ,7 days) review by a stroke specialist followed by
rapid initiation of recommended secondary vascular prevention measures.4,811 Existing medical treatments are
chosen based on TIA etiology with most patients benefiting from antiplatelet medications (relative risk reduction [RRR] 13%28%, absolute risk reduction [ARR] 1.0%1.9%, number needed to treat [NNT] 53104 to
prevent one stroke annually),9,11,12 an HMG-CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reductase
inhibitor (RRR 16%, ARR 0.44%, NNT 230),13,14 and an antihypertensive agent (RRR 24%31%, ARR
0.85%2.20%, NNT 45118).15 Patients with atrial fibrillation benefit most from treatment with an
anticoagulant agent such as warfarin (RRR 67%, ARR 8%, NNT 13) or a new anticoagulant agent such as
a factor IXa or thrombin inhibitor.16
International guidelines recommend diagnostic workup to include brain and vascular imaging and cardiac
investigations.9,11,17 Patients with carotid stenosis of at least 50% ipsilateral to the involved brain tissue should
be considered for carotid endarterectomy within 2 weeks of initial symptoms (NNT 625).9,18 Additional tests
are recommended depending on specific circumstances.9 Behavioral counseling on diabetic control and diet,
exercise, smoking cessation (RRR 33%, ARR 2.3%, NNT 43), and driving are also important.

Rapidly implementing these secondary preventive measures following a TIA is a potentially resource-intensive task and the best way to accomplish
this is unknown. To compare the traditional inpatient model with novel, at least partially outpatient-based
TIA service models, we searched indexed records in MEDLINE (Ovid) from January 1996 to December
IMPLEMENTATION OF SECONDARY STROKE PREVENTION

Editorial, page 888

From the Department of Neurology (A.R.), Wellington Hospital and University of Otago, Wellington; and Department of Neurology (P.A.B.),
Auckland Hospital and Auckland University, New Zealand.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
2016 American Academy of Neurology

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2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

2014 and included subject headings (MeSH terms)

and text words for the target condition (i.e., TIA)
combined with service location (outpatient,
outpatient clinic, inpatient, hospitalization) and/or
other study features (service, cost analysis, outcome
research). This search was supplemented by perusal
of reference lists of TIA review articles.
Both authors reviewed the abstracts of studies
identified by the search (n 5 449) and relevant fulltext articles. Articles were retained if a novel, at least
partially outpatient-based TIA service model description included a prospective evaluation reporting 90day stroke risk. Herein, we describe the traditional
inpatient model and the 6 novel models meeting
our inclusion criteria.
Model 1. Model 1 consists of admitting all patients
with suspected TIA to an inpatient stroke unit, shortstay emergency department, or medical assessment
unit with input from a stroke specialist. This has
the 2-fold advantage of offering rapid expert-driven
implementation of secondary prevention and close
observation. Close observation in the early highrisk period enables treatment with IV alteplase
or endovascular therapy, if a patient goes on to
have an ischemic stroke.19,20 Whether inpatient
observation for this purpose is justified has been
debated.21,22
Model 2. The Melbourne model reported in the Mon-

ash Transient Ischemic Attack Triaging Treatment

(M3T) study23 proposes emergency department assessments under predominantly telephone guidance
from the inpatient stroke team combined with urgent
vascular/brain imaging and followed by immediate
initiation of antiplatelet therapy. Some patients may
still require hospital admission for further management but many are discharged from the emergency
department with outpatient TIA clinic follow-up.
Researchers compared this model with routine
inpatient admission of all potential TIA patients with
a before-and-after design. A 90-day stroke risk of
1.5% was achieved compared with 4.7% before the

Table 1

ABCD2 score7

A 5 Age: 60 y

B 5 Blood pressure: 140/90 mm Hg

C 5 Clinical features
Unilateral weakness

Speech impairment without weakness

D 5 Duration of symptoms
1059 min

60 min

D 5 Diabetes

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Neurology 86

model was implemented where all patients were routinely admitted (adjusted odds ratio [OR] 0.46; 95%
confidence interval [CI] 0.121.68; p 5 0.24).23
While a direct cost analysis was not included, it is
reasonable to assume that this system reduces
hospital-related treatment costs due to the reduced
numbers of admissions. The before-and-after design
of this study raises some concern for potential confounding factors. For example, heightened public
awareness may have led to a higher rate of low-risk
and non-TIA patient presentations in recent years
potentially reducing the 90-day stroke risk in the
after assessment. A further limitation of this study
was that the sample size may have been too small to
demonstrate clear impact on patient outcomes. Details on diagnostic accuracy of the emergency physicians who triaged TIA patients was not provided.
Model 3. The Paris model reported in the SOS-TIA

study10 offers all-hours telephone advice by a nurse

with vascular neurologist backup, specialist TIA clinic
review, and a complete diagnostic workup, all within
6 hours of the referral. This resource-intensive model
bypassed emergency department assessments and
achieved a 90-day stroke rate of 1.2% (95% CI
0.72%2.12%) compared with an ABCD2 stroke
risk prediction of 5.96% (tables 1 and 2).7,10 The
study, like 2 others described below, lacked a
definitive control group. The observed 90-day
stroke risk was compared with a predicted risk
based on historical data. It is possible that an actual
event rate without the intervention would have been
lower than predicted because of overall improved TIA
management over time. This uncertainty reduces the
confidence that the reported benefit represents a
meaningful risk reduction. No cost analysis was
reported although some cost savings can be assumed
given the reduction in hospital admissions. Despite
telephone triage, more than one-third of patients
accessing the hyperacute specialist clinic had nonTIA diagnoses,10 but the rapid specialist input can
help to reduce unnecessary investigations.
Model 4. The Oxford model reported in the
EXPRESS study4 consists of a 2-tier system in
which general practitioners (GPs) refer patients with
suspected TIA or stroke to a routine outpatient TIA/
minor stroke clinic unless they think that the patient
requires immediate hospital admission. This
approach reduces the need for emergency
department and hyperacute vascular neurology
clinic presentations.
This policy was associated with a relatively high
90-day stroke risk of 10.3%. However, in phase 2
of the EXPRESS study, same day open access clinics during weekday office hours were provided,
avoiding the need for patient appointment booking

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2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Table 2

Risk stratification by ABCD2 score7

ABCD2 score
Low risk

High risk

03

45

67

34

45

21

1.0

4.1

8.1

7d

1.2

5.9

11.7

90 d

3.1

9.8

17.8

Proportion of all TIAs, %

Stroke risk (%) at
2d

and related delays. Stroke physicians also initiated

best medical therapy immediately rather than writing
back to patients GPs with recommendations. These
phase-2 interventions were associated with an
improvement in 90-day stroke risk, which dropped
to 2.1% (adjusted hazard ratio 0.20, 95% CI 0.08
0.49; p 5 0.0001).4 The open-access system reduced
the median time from GP to specialist review from 3
days (interquartile range [IQR] 25) to 1 day (IQR
03) (p , 0.0001). Median time to initiation of relevant non-antiplatelet medications dropped from 20
days (IQR 853) to 1 day (IQR 03) (p , 0.001).
Point estimates and CIs were not reported for these
outcomes.
Strengths of the EXPRESS study included the
large sample size and presence of a definitive control
group. However, as with the model 2 (M3T) evaluation, the study used a before-and-after design that
does not effectively control for other health system
or management changes occurring over time. Also,
the criteria for assigning in- vs outpatient assessments
were not clearly described and a cost analysis was not
included. Nonetheless, the primary care triage system
reduced emergency department visits and after-hour
specialist reviews and thus likely added further cost
savings.
Model 5. The Stanford model24 uses the ABCD2

stroke risk assessment score (table 1)7 to triage patients for inpatient admissions (ABCD2 score of
.3) or outpatient (#3) assessments with early brain,
and intra- and extracranial vessel imaging.
The Two-Aces observational cohort study compared observed stroke rate with predicted stroke rate
based on ABCD2 score (table 2). The observed 90day stroke rate was 0.9% (0.3%3.2%), which was
less than expected based on ABCD2 scores (p 5
0.001). Point estimates were not provided. The use
of a validated scoring system with clear triage parameters is a strength of this study and model. However,
to access this triage system, all potential patients
(including the 20%50% TIA mimics) still had to

present to the emergency department. Of the 224

patients in this cohort, 49% ended up with a specialist non-TIA diagnosis but still underwent immediate
imaging. Therefore, this system relies heavily on the
availability of acute secondary services including rapid
access to diagnostic tests, a potentially inefficient use
of health care resources.24 Again, a control group was
not included as part of the evaluation and no economic analysis was provided to confirm presumed
cost savings.
Model 6. The Ottawa model25 consists of a tiered

system where patients are triaged into low, intermediate, and high stroke risk relying predominantly on
the ABCD2 score with outpatient specialist clinic
review occurring between 0 and 7 days for high-risk
patients and more than 14 days for low-risk patients.
Similar to models 2 (Melbourne) and 5 (Stanford), all
patients are seen in the emergency department and
undergo immediate ECG and brain imaging,
although they generally do not receive immediate
specialist input. All potential TIA patients also
undergo urgent outpatient echocardiograms, 24-hour
Holter monitoring, and carotid Doppler examinations.
An evaluation revealed that the 90-day stroke rate
in this model was 3.2%, which compared favorably
to a predicted risk of 9.1% (95% CI 2.1%4.3%)
based on the ABCD2 score (p , 0.0001). The authors did not present a figure for the accuracy of
their emergency physician TIA diagnoses or a cost
analysis although reduced reliance on rapid specialist
review likely offered a resource benefit to their
health system.
Model 7. The New Zealand model reported in the

FASTEST trial,26 uses an electronic decision support

tool in primary care. Patients presenting to their GP
are assessed using a Web-based tool that integrates
with the electronic primary care medical record.
The tool helps the GP to confirm a likely diagnosis
of TIA, provide triage advice, and initiate appropriate
management at first point of contact. The triage
advice is based on TIA guidelines where high-risk
patients are defined as people with one or more of the
following features: ongoing neurologic symptoms, an
ABCD2 score of .3, 2 or more events over the
preceding 7 days, presence of atrial fibrillation, or
current treatment with anticoagulants.9 Patients at
high risk of stroke are triaged to specialist review
within 24 hours and lower-risk patients are triaged
to be seen at the outpatient specialist TIA clinic
within 7 days. Non-TIA symptoms such as syncope
result in a request to reconsider the diagnosis. Patients
who cannot access specialist care within the stipulated
time frame can be managed by the GP with direct
access to investigations if the electronic decision
support tool endorses this management step.
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950
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Table 3

Comparison of noninpatient-based TIA service models (models 27)a

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Model 2, Melbourne, M3T (2012)

Model 3, Paris, SOS-TIA (2007)

Model 4, Oxford, EXPRESS (2007)

Trial design; patient inclusion criteriab

Patient inclusionb

90-d stroke risk

(active), n/n (%)

90-d stroke risk

(control), n/n (%)

Adjusted odds or
hazard ratio (95% CI)

Sequential cohort; all patients evaluated in

emergency department with possible TIA

Per protocol

7/468 (1.5)

7/150 (4.7)

0.46 (0.121.68)

0.24

Specialist confirmed TIA/stroke

7/296 (2.4)

7/114 (6.1)

0.43 (0.121.59)

0.21

Case series; all patients evaluated by vascular

neurologist following RN telephone screen

Sequential cohort; specialist confirmed TIA/stroke

referred to outpatient TIA clinic

Per protocol

13/1052 (1.2)

(5.96)

Specialist confirmed TIA/stroke

13/824 (1.6)

Per protocol

6/281 (2.1)

32/310 (10.3)

0.20 (0.080.49)

,0.001

Including inpatient referrals

27/644 (4.2)

63/634 (9.9)

,0.001

(7.1)

,0.001

Per protocol

2/223 (0.9)

Model 5, Stanford, Two-Aces (2011)

Case series; all patients evaluated in emergency

department with possible TIA

Specialist confirmed TIA/stroke

2/116 (1.7)

(7.9)

0.03

Model 6, Ottawa (2010)

Case series; all patients evaluated in emergency

department with possible TIA

Per protocol

31/982 (3.2)

(9.1)

,0.001

Model 7, New Zealand, FASTEST

(2015)

Cluster randomized controlled trial; all patients evaluated

by GPs with possible TIA

Per protocol

2/172 (1.2)

5/119 (4.2)

0.27 (0.051.41)

0.098

ABCD2 predicted

2/172 (1.2)

(7.8)c

0.001

Specialist confirmed TIA/stroke

2/99 (2.2)

5/69 (7.3)

Abbreviations: CI 5 confidence interval; GP 5 general practitioner; M3T 5 Monash Transient Ischemic Attack Triaging Treatment.
a
Model 1, inpatients-based TIA care, is considered the gold standard but current data of its efficacy if used in 100% of TIA patients are not available.
b
The denominator for calculating stroke rate differed between studies. Notably, EXPRESS excluded all TIA mimickers and inpatients, while all other researchers included these groups. Data in addition to primary
endpoints are provided to assist with interstudy comparisons.
c
These studies used published risk predictions for ABCD2 scores rather than their own controls except the FASTEST trial where the comparison to ABCD2-predicted outcomes was added as a post hoc analysis to
allow interstudy comparison.

2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Model 7 has been tested in the cluster randomized

controlled FASTEST trial that found patients managed by GPs with access to the electronic decision
support tool received more guideline adherent care
(76.2%) than controls (41.2%) (adjusted OR 4.57;
95% CI 2.398.71; p , 0.001), and patients were
less likely to have vascular events or to have died by
day 90 (3.5% vs 11.9%; adjusted OR 0.27; 95% CI
0.090.78; p 5 0.016). This is the only randomized
controlled trial assessing a novel TIA service model.
A weakness of this study is that it was underpowered to show a significant reduction in the 90-day
stroke risk (p 5 0.098), likely because of a lower
observed 90-day stroke rate than was predicted by
the ABCD2 (4.2% vs 9.2%) that was used to calculate the sample size.7 Had the intervention been compared with its own ABCD2 score case-mix-adjusted
90-day stroke risk of 7.8%, the result would have
been significant at p 5 0.001.
The FASTEST trial included a cost analysis that
demonstrated a cost ratio of 0.65 (0.470.91; p 5
0.01) favoring the use of the electronic support tool.
This cost saving was attributed to improved GP diagnostic accuracy with use of the tool (positive predictive value 66% vs 57% in control, and negative
predictive value 74% vs 40% in control group) resulting in more appropriate use of specialist and diagnostic services.27 Table 3 summarizes the outpatient
models.
DISCUSSION TIA is a medical emergency and requires urgent intervention to maximize secondary
prevention and thus minimize the risk of subsequent
stroke. A policy of admitting all patients with suspected
TIA to the hospital will result in the admission of large
numbers of non-TIA/stroke patients (20%50% of
the total) because of the high false-positive rate of
initial nonexpert TIA diagnosis.2830 This leads to
inefficient use of expensive health care resources.
Some high-risk stroke patients may have to compete
for urgent investigations with low-risk or non-TIA
patients resulting in unnecessary management delays.
Recent evidence demonstrates that the benefit of rapid
access to thrombolysis and hospitalization in general
does not justify this resource investment unless the risk
of very early stroke is above 4%.31,32
Models 2 (Melbourne) and 3 (Paris) reduce hospital
admissions and demonstrate low 90-day stroke risk but
it is not clear that these models improve overall health
care efficiency beyond reducing hospital bed days. In
model 2, the hyperacute assessments performed by
emergency medicine physicians with specialist telephone advice risk misdiagnosis and potential overinvestigation of non-TIAs.33 In model 3, stroke specialist
input and diagnostic workup is still required 24 hours,
7 days per week. Hyperacute vascular neurology review

presumably reduces unnecessary investigations and

adds diagnostic benefits although similar patient outcomes were achieved with other models. In addition,
24-hour, 7 days per week vascular neurology availability
may be more costly than emergency department generalist assessment and this model may only be achievable in major tertiary centers. Neither model 2 nor 3
places a significant emphasis on reducing hyperacute
secondary or tertiary assessments of low-risk patients
or TIA mimics.
In an attempt to reduce requirements for hyperacute vascular neurology input and further improve
health care efficiency, models 4, 5, 6, and 7 use a
2-tiered risk stratification system that referring clinicians may use without requiring immediate stroke
specialist input. In these systems, only the most at
risk TIA patients undergo inpatient or hyperacute
stroke specialist assessments and others are referred to
less urgent outpatient specialist clinics.7,2426,34
In models 4 and 5 (Oxford and Stanford), most
patients still undergo urgent specialist assessment
within 1 to 2 days of initial presentation and in model
5 (Stanford) all patients were seen in the emergency
department regardless of risk prediction and underwent urgent imaging. In this respect, model 5 does
not significantly improve on model 2 (Melbourne)
in terms of health resource utilization.
Model 6 (Ottawa) provides some evidence that
longer delays in outpatient specialist assessments
may be feasible, offering more flexibility to the health
services although 90-day stroke risk may be slightly
higher. Reliance on secondary services for initial assessments and rapid undifferentiated diagnostic
workup of all potential TIA patients regardless of triage score remains an issue. Thus, aside from adding
more flexibility in timing specialist access, model 6
largely resembles the other models except for model
4 (Oxford).
Model 7 (New Zealand) is similar to models 4 to 6
except that generalist diagnosis is supported by an electronic decision support tool. Like model 4 (Oxford),
triage occurs before presentation to secondary care.
This results in reduced costs associated with unwarranted emergency department or urgent specialist
review and prevents unnecessary investigations, while
achieving similar 90-day stroke rates.27 Model 7 also
reduces referrals of non-TIA patients, increases referral
of true TIA patients, and provides management advice
and investigation access to GPs.35 This helps to address
geographic, socioeconomic, and cultural access barriers.3640 The electronic decision support tool may
not be readily compatible with all existing primary care
electronic health record systems and requires internet
access, introducing potential implementation barriers.
It has to be recognized that these different models
evolved in different health care systems. Some systems
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951

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rely more heavily on primary care referral to secondary

services than others. This may have influenced the
resultant service models, which have often developed
around the resources available locally.
All presented models appear to lower event rates
despite varying degrees of intensity and treatment delays. Most study designs raise the possibility that overall
TIA care improved over time and that this improvement
may be unrelated to service model. The FASTEST trial
provides evidence that improvements were not entirely
attributable to temporal trends although even here the
control group had a lower than expected 90-day stroke
risk and the intervention benefit only trended toward
significance. A conservative conclusion would be that
the new outpatient models are safe and that recently
observed stroke risk following TIA is lower than suggested by historical estimates.
We considered performing a meta-analysis, but
the differences in design/inclusion criteria did not
enable this. If raw data were made available, further
modeling to explore the most critical interventions
and optimal treatment time frames might be possible
despite design differences. Despite conducting a systematic review, we may have inadvertently omitted
other TIA service models.
Finally, the reviewed 2-tiered models largely rely on
the ABCD2 score, the predictive value of which, when
used in isolation, has been called into question.41
Given that these ABCD2-based models achieved 90day stroke risks of approximately 1%, it will be difficult
for improved risk scores to demonstrate a clear outcome advantage over the ABCD2 or ABCD21, but if
deemed appropriate, the TIA service models presented
here could readily adopt a new score. From a health
optimization perspective, risk scores add the greatest
value if aimed at preinvestigation primary and emergency care providers rather than post-MRI vascular
neurologists.
Risk stratification performed at the time of first
health care contact helps primary care providers to
identify patients in greatest need of urgent investigation and specialist review. Most reported models
continue to rely on referral or self-presentation of
all potential TIA patients either for rapid specialist
input or emergency department assessments coupled
with comprehensive diagnostic workup. A service
model that utilizes a novel electronic decision
support tool for GPs that considers multiple other
clinical features on top of the ABCD2 score is the
latest addition to the suite of TIA service models
and may provide a significant combined advantage
of health outcome and resource optimization. However, regional variations may require different models to suit local needs and resource availabilities and
this review compares and contrasts several effective
models to choose from.
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Neurology 86

Ongoing research into the optimization of TIA

and stroke service delivery is becoming increasingly
important. Future studies should ideally include
health economic assessments to more effectively help
advise health sector planning. Implementing existing
best practice strategies to reach the broader population should be pursued with the same vigor as efforts
to discover new treatment strategies.
AUTHOR CONTRIBUTIONS
A. Ranta reviewed the literature and created the first draft, contributed to
subsequent versions, and approved the final version of the manuscript.
P. A. Barber reviewed the literature, critically reviewed the first draft
and contributed to subsequent versions, and approved the final version
of the manuscript.

STUDY FUNDING
No targeted funding reported.

DISCLOSURE
The authors report no disclosures relevant to the manuscript. Go to
Neurology.org for full disclosures.

Received May 28, 2015. Accepted in final form October 7, 2015.

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Neurology 86

March 8, 2016

953

2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Transient ischemic attack service provision: A review of available service models

Annemarei Ranta and P. Alan Barber
Neurology 2016;86;947-953 Published Online before print January 22, 2016
DOI 10.1212/WNL.0000000000002339
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References

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