Introduction: Previous work suggests that early evaluation and treatment may reduce the stroke risk after TIA by up to 80%. These models of care are resource intensive involving same day access to stroke prevention services, often in urban areas. This is not feasible in many settings, especially where large distances and rural populations are concerned.
Hypothesis: We hypothesize that implementation of a province-wide, systematic, multifaceted intervention would lower the recurrent stroke rate in Alberta.
Methods: This was a prospective quasi-experimental health services research in the province of Alberta involving a population of 4 million living in an area larger than France (660,000 km2). The ASPIRE interventions, implemented over 15 months, involved education to the public and healthcare providers, creation of a triaging algorithm based on clinical symptoms and onset time, and a 24-7 available TIA Hotline for rapid access to stroke expertise. The primary outcome was the 90-day stroke rate tested with an interrupted time-series regression analysis. Stroke outcomes were adjudicated by two stroke neurologists independently with discrepancies resolved by panel. Secondary outcomes were the composite of stroke, myocardial infarction, death, and the individual components from administrative data tested with age-sex adjusted logistic regression analysis.
Results: We included 15709 TIA events in 13671 patients. Age-sex adjusted rate (and %) of stroke recurrence was 1.81 per 100,000 (1.85%) pre-implementation and 1.79 (1.65%) post. The primary outcome was neutral (autoregression coefficient 0.13, p-value 0.70). The 90-day mortality was significantly lower post-implementation (OR 0.75, 95%CI 0.60-0.94). There was a trend in decreased composite endpoint of stroke, myocardial infarction, and death (OR 0.88, 95%CI 0.77-1.01).
Conclusions: In a population with low stroke recurrence rates, the successful province-wide implementation of the ASPIRE interventions was associated with decreased mortality, but did not significantly change stroke recurrence. Further studies on improving the identification of high-risk patients is necessary.