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Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results

Alan Watkins Orcid Logo, Jenna Jones, Khalid Ali, Richard Dewar, Adrian Edwards, Bridie Evans Orcid Logo, Lyn Evans, Gary A Ford, Chelsey Hampton, Roger John, Charlene Jones, Chris Moore Orcid Logo, Michael Obiako, Alison Porter Orcid Logo, Alan Pryce, Tom Quinn, Anne Seagrove, Helen Snooks Orcid Logo, Shirley Whitman, Nigel Rees

Emergency Medicine Journal, Volume: 41, Issue: 12, Pages: 710 - 716

Swansea University Authors: Alan Watkins Orcid Logo, Jenna Jones, Bridie Evans Orcid Logo, Alison Porter Orcid Logo, Anne Seagrove, Helen Snooks Orcid Logo

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DOI (Published version): 10.1136/emermed-2021-212230

Abstract

Background Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require...

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Published in: Emergency Medicine Journal
ISSN: 1472-0205 1472-0213
Published: BMJ 2024
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URI: https://cronfa.swan.ac.uk/Record/cronfa67694
first_indexed 2024-09-16T10:27:00Z
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fullrecord <?xml version="1.0"?><rfc1807><datestamp>2024-11-29T14:53:12.7681865</datestamp><bib-version>v2</bib-version><id>67694</id><entry>2024-09-16</entry><title>Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results</title><swanseaauthors><author><sid>81fc05c9333d9df41b041157437bcc2f</sid><ORCID>0000-0003-3804-1943</ORCID><firstname>Alan</firstname><surname>Watkins</surname><name>Alan Watkins</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>e662b6c5aba239a9cd0f115d16df0a82</sid><ORCID/><firstname>Jenna</firstname><surname>Jones</surname><name>Jenna Jones</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>6098eddc58e31ac2f3e070cb839faa6a</sid><ORCID>0000-0003-0293-0888</ORCID><firstname>Bridie</firstname><surname>Evans</surname><name>Bridie Evans</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>fcc861ec479a79f7fb9befb13192238b</sid><ORCID>0000-0002-3408-7007</ORCID><firstname>Alison</firstname><surname>Porter</surname><name>Alison Porter</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>33ab56cb67d7b1ef58f0280af1744e0d</sid><ORCID/><firstname>Anne</firstname><surname>Seagrove</surname><name>Anne Seagrove</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>ab23c5e0111b88427a155a1f495861d9</sid><ORCID>0000-0003-0173-8843</ORCID><firstname>Helen</firstname><surname>Snooks</surname><name>Helen Snooks</name><active>true</active><ethesisStudent>false</ethesisStudent></author></swanseaauthors><date>2024-09-16</date><deptcode>MEDS</deptcode><abstract>Background Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown.Aim To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED.Methods The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients&#x2019; allocation determined by that of attending paramedics.Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness.Results From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score &gt;3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI &#x2212;0.0371, 0.0183), p=0.475.Conclusion The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended.</abstract><type>Journal Article</type><journal>Emergency Medicine Journal</journal><volume>41</volume><journalNumber>12</journalNumber><paginationStart>710</paginationStart><paginationEnd>716</paginationEnd><publisher>BMJ</publisher><placeOfPublication/><isbnPrint/><isbnElectronic/><issnPrint>1472-0205</issnPrint><issnElectronic>1472-0213</issnElectronic><keywords/><publishedDay>21</publishedDay><publishedMonth>11</publishedMonth><publishedYear>2024</publishedYear><publishedDate>2024-11-21</publishedDate><doi>10.1136/emermed-2021-212230</doi><url/><notes/><college>COLLEGE NANME</college><department>Medical School</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>MEDS</DepartmentCode><institution>Swansea University</institution><apcterm>SU Library paid the OA fee (TA Institutional Deal)</apcterm><funders>Health and Care Research Wales - 1053</funders><projectreference/><lastEdited>2024-11-29T14:53:12.7681865</lastEdited><Created>2024-09-16T11:24:41.6474404</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">Swansea University Medical School - Biomedical Science</level></path><authors><author><firstname>Alan</firstname><surname>Watkins</surname><orcid>0000-0003-3804-1943</orcid><order>1</order></author><author><firstname>Jenna</firstname><surname>Jones</surname><orcid/><order>2</order></author><author><firstname>Khalid</firstname><surname>Ali</surname><order>3</order></author><author><firstname>Richard</firstname><surname>Dewar</surname><order>4</order></author><author><firstname>Adrian</firstname><surname>Edwards</surname><order>5</order></author><author><firstname>Bridie</firstname><surname>Evans</surname><orcid>0000-0003-0293-0888</orcid><order>6</order></author><author><firstname>Lyn</firstname><surname>Evans</surname><order>7</order></author><author><firstname>Gary A</firstname><surname>Ford</surname><order>8</order></author><author><firstname>Chelsey</firstname><surname>Hampton</surname><order>9</order></author><author><firstname>Roger</firstname><surname>John</surname><order>10</order></author><author><firstname>Charlene</firstname><surname>Jones</surname><order>11</order></author><author><firstname>Chris</firstname><surname>Moore</surname><orcid>0000-0002-2192-3002</orcid><order>12</order></author><author><firstname>Michael</firstname><surname>Obiako</surname><order>13</order></author><author><firstname>Alison</firstname><surname>Porter</surname><orcid>0000-0002-3408-7007</orcid><order>14</order></author><author><firstname>Alan</firstname><surname>Pryce</surname><order>15</order></author><author><firstname>Tom</firstname><surname>Quinn</surname><order>16</order></author><author><firstname>Anne</firstname><surname>Seagrove</surname><orcid/><order>17</order></author><author><firstname>Helen</firstname><surname>Snooks</surname><orcid>0000-0003-0173-8843</orcid><order>18</order></author><author><firstname>Shirley</firstname><surname>Whitman</surname><order>19</order></author><author><firstname>Nigel</firstname><surname>Rees</surname><order>20</order></author></authors><documents><document><filename>67694__32698__e09e2a7b0a16487a9f4d666607e793e7.pdf</filename><originalFilename>67694.VoR.pdf</originalFilename><uploaded>2024-10-24T13:41:21.7598412</uploaded><type>Output</type><contentLength>432244</contentLength><contentType>application/pdf</contentType><version>Version of Record</version><cronfaStatus>true</cronfaStatus><documentNotes>&#xA9; Author(s) (or their employer(s)) 2024. 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spelling 2024-11-29T14:53:12.7681865 v2 67694 2024-09-16 Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results 81fc05c9333d9df41b041157437bcc2f 0000-0003-3804-1943 Alan Watkins Alan Watkins true false e662b6c5aba239a9cd0f115d16df0a82 Jenna Jones Jenna Jones true false 6098eddc58e31ac2f3e070cb839faa6a 0000-0003-0293-0888 Bridie Evans Bridie Evans true false fcc861ec479a79f7fb9befb13192238b 0000-0002-3408-7007 Alison Porter Alison Porter true false 33ab56cb67d7b1ef58f0280af1744e0d Anne Seagrove Anne Seagrove true false ab23c5e0111b88427a155a1f495861d9 0000-0003-0173-8843 Helen Snooks Helen Snooks true false 2024-09-16 MEDS Background Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown.Aim To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED.Methods The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients’ allocation determined by that of attending paramedics.Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness.Results From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score >3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI −0.0371, 0.0183), p=0.475.Conclusion The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended. Journal Article Emergency Medicine Journal 41 12 710 716 BMJ 1472-0205 1472-0213 21 11 2024 2024-11-21 10.1136/emermed-2021-212230 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University SU Library paid the OA fee (TA Institutional Deal) Health and Care Research Wales - 1053 2024-11-29T14:53:12.7681865 2024-09-16T11:24:41.6474404 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Biomedical Science Alan Watkins 0000-0003-3804-1943 1 Jenna Jones 2 Khalid Ali 3 Richard Dewar 4 Adrian Edwards 5 Bridie Evans 0000-0003-0293-0888 6 Lyn Evans 7 Gary A Ford 8 Chelsey Hampton 9 Roger John 10 Charlene Jones 11 Chris Moore 0000-0002-2192-3002 12 Michael Obiako 13 Alison Porter 0000-0002-3408-7007 14 Alan Pryce 15 Tom Quinn 16 Anne Seagrove 17 Helen Snooks 0000-0003-0173-8843 18 Shirley Whitman 19 Nigel Rees 20 67694__32698__e09e2a7b0a16487a9f4d666607e793e7.pdf 67694.VoR.pdf 2024-10-24T13:41:21.7598412 Output 432244 application/pdf Version of Record true © Author(s) (or their employer(s)) 2024. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license. true eng https://creativecommons.org/licenses/by/4.0/
title Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
spellingShingle Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
Alan Watkins
Jenna Jones
Bridie Evans
Alison Porter
Anne Seagrove
Helen Snooks
title_short Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
title_full Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
title_fullStr Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
title_full_unstemmed Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
title_sort Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results
author_id_str_mv 81fc05c9333d9df41b041157437bcc2f
e662b6c5aba239a9cd0f115d16df0a82
6098eddc58e31ac2f3e070cb839faa6a
fcc861ec479a79f7fb9befb13192238b
33ab56cb67d7b1ef58f0280af1744e0d
ab23c5e0111b88427a155a1f495861d9
author_id_fullname_str_mv 81fc05c9333d9df41b041157437bcc2f_***_Alan Watkins
e662b6c5aba239a9cd0f115d16df0a82_***_Jenna Jones
6098eddc58e31ac2f3e070cb839faa6a_***_Bridie Evans
fcc861ec479a79f7fb9befb13192238b_***_Alison Porter
33ab56cb67d7b1ef58f0280af1744e0d_***_Anne Seagrove
ab23c5e0111b88427a155a1f495861d9_***_Helen Snooks
author Alan Watkins
Jenna Jones
Bridie Evans
Alison Porter
Anne Seagrove
Helen Snooks
author2 Alan Watkins
Jenna Jones
Khalid Ali
Richard Dewar
Adrian Edwards
Bridie Evans
Lyn Evans
Gary A Ford
Chelsey Hampton
Roger John
Charlene Jones
Chris Moore
Michael Obiako
Alison Porter
Alan Pryce
Tom Quinn
Anne Seagrove
Helen Snooks
Shirley Whitman
Nigel Rees
format Journal article
container_title Emergency Medicine Journal
container_volume 41
container_issue 12
container_start_page 710
publishDate 2024
institution Swansea University
issn 1472-0205
1472-0213
doi_str_mv 10.1136/emermed-2021-212230
publisher BMJ
college_str Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Biomedical Science{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Biomedical Science
document_store_str 0
active_str 0
description Background Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown.Aim To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED.Methods The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients’ allocation determined by that of attending paramedics.Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness.Results From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score >3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI −0.0371, 0.0183), p=0.475.Conclusion The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended.
published_date 2024-11-21T14:36:47Z
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score 11.048042

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