RT Journal Article
SR Electronic
T1 When has service provision for transient ischaemic attack improved enough? A discrete event simulation economic modelling study
JF BMJ Open
JO BMJ Open
FD British Medical Journal Publishing Group
SP e018189
DO 10.1136/bmjopen-2017-018189
VO 7
IS 11
A1 Pelham Barton
A1 James P Sheppard
A1 Cristina M Penaloza-Ramos
A1 Sue Jowett
A1 Gary A Ford
A1 Daniel Lasserson
A1 Jonathan Mant
A1 Ruth M Mellor
A1 Tom Quinn
A1 Peter M Rothwell
A1 David Sandler
A1 Don Sims
A1 Richard J McManus
A1 ,
YR 2017
UL http://bmjopen.bmj.com/content/7/11/e018189.abstract
AB Objectives The aim of this study was to examine the impact of transient ischaemic attack (TIA) service modification in two hospitals on costs and clinical outcomes.Design Discrete event simulation model using data from routine electronic health records from 2011.Participants Patients with suspected TIA were followed from symptom onset to presentation, referral to specialist clinics, treatment and subsequent stroke.Interventions Included existing versus previous (less same day clinics) and hypothetical service reconfiguration (7-day service with less availability of clinics per day).Outcome measures The primary outcome of the model was the prevalence of major stroke after TIA. Secondary outcomes included service costs (including those of treating subsequent stroke) and time to treatment and attainment of national targets for service provision (proportion of high-risk patients (according to ABCD2 score) seen within 24 hours).Results The estimated costs of previous service provision for 490 patients (aged 74±12 years, 48.9% female and 23.6% high risk) per year at each site were £340 000 and £368 000, respectively. This resulted in 31% of high-risk patients seen within 24 hours of referral (47/150) with a median time from referral to clinic attendance/treatment of 1.15 days (IQR 0.93–2.88). The costs associated with the existing and hypothetical services decreased by £5000 at one site and increased £21 000 at the other site. Target attainment was improved to 79% (118/150). However, the median time to clinic attendance was only reduced to 0.85 days (IQR 0.17–0.99) and thus no appreciable impact on the modelled incidence of major stroke was observed (10.7 per year, 99% CI 10.5 to 10.9 (previous service) vs 10.6 per year, 99% CI 10.4 to 10.8 (existing service)).Conclusions Reconfiguration of services for TIA is effective at increasing target attainment, but in services which are already working efficiently (treating patients within 1–2 days), it has little estimated impact on clinical outcomes and increased investment may not be worthwhile.