Lancet: Urgent, outpatient stroke treatment could save $100M
Urgent assessment and treatment of patients who have had a minor stroke, or transient ischemic attack (TIA), in a specialist emergency outpatient clinic reduces disability, hospital bed-days and costs, according to the second part of the EXPRESS study, published online Feb.4 and will appear in the March edition of Lancet Neurology.

Peter Rothwell, MD, and colleagues from the stroke prevention research unit at John Radcliffe Hospital in Oxford, England, and the University of Oxford, said that the risk of recurrent stroke in the first few days after a minor stroke or TIA is around 8 to 10 percent.

The first part of the EXPRESS study, reported in October 2007, found that urgent assessment and immediate treatment at a specialist clinic (phase 2) reduced the risk of recurrent stroke within the first 90 days by 80 percent, compared with patients treated at a standard referral appointment-based clinic (phase 1). This follow-up study aimed to compare the effects of phase 2 versus phase 1 with regard to hospital admissions, cost and disability after six months, the researchers said.

The authors found that phase 2 patients had a lower 90-day risk of fatal or disabling stroke--this occurred in only 1 of 281 phase 2 patients compared with 16 of 310 in phase 1.

Rothwell and colleagues also reported that hospital admissions in phase 2 were much lower (five admissions) than in phase 1 (25 admissions). Hospital bed-days used due to stroke and other cardiovascular causes were also much lower in phase 2 (427 days) than phase 1 (1365 days). This generated savings of an average of £624 per patient ($930.41, U.S.) referred to the phase 2 clinic.

"In the U.K., most patients with TIA or minor stroke are managed in weekly outpatient clinics after referral by a primary-care physician. This system results in about half of all patients waiting for more than 14 days to be assessed and treated, during which time the risk of recurrent stroke is at its highest," according to the authors.

"The EXPRESS study showed that urgent assessment of TIA and minor stroke in combination with early initiation of preventive treatment reduced the risk of early recurrent stroke by about 80 percent. This further analysis shows that, for patients referred to the EXPRESS study outpatient clinic, there were also reductions in fatal or disabling recurrent strokes, 90-day hospital bed-days, costs of admission to hospital, and overall disability levels at six months' follow-up," they wrote.

"The extrapolation of these results [for the U.K. as a whole] would prevent about 10,000 strokes annually, and would generate savings of 290,000 hospital bed-days and monetary savings of £68 million [$101.4 million] in acute-care costs alone," the authors wrote. "In addition, the reductions in disability rates at six months might lead to a reduction in the long-term usage of the health service in the community."

In an accompanying commentary, Naeem Dean, MD, and Ashfaq Shuaib, MD, from Royal Alexandra Hospital and University of Alberta in Edmonton, Canada, wrote that the "care of patients with stroke, and the prevention of further events in patients who present with TIAs, will, unfortunately, always be suboptimum, as long as we fail to equate TIA and stroke care in line with the way we manage patients with acute coronary disorders. We hope that the research work emanating from several stroke centers, including those in Oxfordshire, will bring awareness to this under-recognized and poorly treated but common condition."