Capsule Commentary on Homoya et al., Uncertainty as a Key Influence in the Decision to Admit Patients with Transient Ischemic Attack
In this study, Homoya and colleagues explore the real-world management of patients with TIAs in 14 VA Medical Centers from around the country. A TIA is an example of an infrequent but high-risk event that non-specialists need to recognize and appropriately manage.1 What happens in the first few days after having a TIA is critical since the risk of a potentially disabling stroke is greater than 10% and the risk of death is 2.6% at 90 days.2
The authors demonstrate that TIA management is suboptimal for many patients and that providers have an incorrect estimation regarding management of TIA patients by their facility, believing that almost all TIA patients were admitted to inpatient setting for workup, management of risk factors, and treatment when in fact many patients are not admitted. This is illustrated in the qualitative section in which a staff member said “Most probably do get admitted” (meaning people with a TIA) when in fact more than a third of patients at that facility with TIA were discharged from the ED.
The underlying theme in this study is uncertainty. Providers are uncertain of what to do because they lack guidance from their facility, they are uncertain of the appropriate evaluation and management of this infrequent but high-risk event in which the patient looks and feels well, and there is pressure to reduce “unnecessary” hospital admissions. Clear guidelines could be helpful; implementation science and quality improvement interventions could reduce uncertainty by testing “TIA protocols” to address key element of the admission decision-making process and to standardize both evaluation of TIA and delivery of secondary prevention strategies.3,4
Compliance with Ethical Standards
Conflict of Interest
The author declares that he does not have a conflict of interest.
- 1.Homoya BJ, Damush TM, Sico JJ, Miech EJ, Arling GW, Myers LJ, Ferguson JB, Phipps MS, Cheng EM, Bravata DM. Uncertainty as a Key Influence in the Decision to Admit Patients with Transient Ischemic Attack. J Gen Intern Med. https://doi.org/10.1007/s11606-018-4735-9
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