ARTICLE OPEN ACCESS CLASS OF EVIDENCE

Specialized Outpatient Clinic vs Stroke Unit forTIA and Minor StrokeA Cohort Study

Sidsel Hastrup MD PhD Soren P Johnsen MD PhD Martin Jensen MSc

Paul von Weitzel-Mudersbach MD PhD Claus Z Simonsen MD PhD Niels Hjort MD PhD

Anette T Moslashller MD PhD Thomas Harbo MD PhD Marika S Poulsen MD Helle K Iversen MD DMSci

Dorte Damgaard MD PhD and Grethe Andersen MD DMSci

Neurologyreg 202196e1096-e1109 doi101212WNL0000000000011453

Correspondence

Dr Hastrup

sidshastrmdk

AbstractObjectiveTo evaluate the effects of an outpatient clinic setup for minor strokeTIA using subsequentadmission of patients at high risk of recurrent stroke

MethodsWe performed a cohort study of all patients with suspected minor strokeTIA seen in anoutpatient clinic at Aarhus University Hospital Denmark between September 2013 and Au-gust 2014 Patients with stroke were compared to historic (same hospital) and contemporary(another comparable hospital) matched hospitalized controls on nonprioritized outcomeslength of stay readmissions care quality (10 processndashperformance measures) and mortalityPatients with TIA were compared to contemporary matched hospitalized controls Followingcomplete diagnostic workup patients with strokeTIA were classified into lowhigh risk ofrecurrent stroke le7 days

ResultsWe analyzed 1076 consecutive patients of whom 253 (235) were subsequently admitted tothe stroke ward StrokeTIA was diagnosed in 215171 patients respectively Fifty-six percent(121215) of the patients with stroke were subsequently admitted to the stroke ward Com-parison with the historic stroke cohort (n = 191) showed a shorter acute hospital stay for thestrokes (median 1 vs 3 days adjusted length of stay ratio 049 95 confidence interval033ndash071) Thirty-day readmission rate was 32 vs 116 (adjusted hazard ratio 023[009ndash059]) and care quality was higher with a risk ratio of 130 (115ndash147) The comparisonof stroke and TIAs to contemporary controls showed similar results Only one patient in thelow risk category and not admitted experienced stroke within 7 days (06)

ConclusionsAn outpatient clinic setup for patients with minor strokeTIA yields shorter acute hospital staylower readmission rates and better quality than hospitalization in stroke units

Classification of EvidenceThis study provides Class III evidence that a neurovascular specialistndashdriven outpatient clinicfor patients with minor strokeTIA with the ability of subsequent admission is safe and yieldsshorter acute hospital stay lower readmission rates and better quality than hospitalization instroke units

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PodcastWill Rondeau speaks withDr Sidsel Hastrup aboutinpatient vs outpatientmanagement of TIA andstroke

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From the Danish Stroke Centre Neurology (SH PvW-M CZS NH ATM TH MSP DD GA) Aarhus University Hospital Department of Clinical Medicine Health (SHCZS NH GA) Aarhus University Danish Center for Clinical Health Services Research Department of Clinical Medicine (SPJ MJ) Aalborg University Stroke Centre Rig-shospitalet Department of Neurology (HKI) Rigshospitalet and Faculty of Health and Medical Sciences (HKI) University of Copenhagen Denmark

Go to NeurologyorgN for full disclosures Funding information and disclosures deemed relevant by the authors if any are provided at the end of the articleThe Article Processing Charge was funded by the University of Aarhus Denmark the Lundbeck Foundation Denmark and the Laerdal Foundation Norway

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 40 (CC BY-NC-ND) which permits downloadingand sharing the work provided it is properly cited The work cannot be changed in any way or used commercially without permission from the journal

e1096 Copyright copy 2021 The Author(s) Published by Wolters Kluwer Health Inc on behalf of the American Academy of Neurology

Patients with minor strokeTIA are at high risk of a recurrentischemic event12 but landmark studies show a dramatic effectof immediate hospital referral34 It has long been known thatpatients in an organized inpatient stroke unit fare better thanthose in a general ward56 and it is feasible and cost-effectiveto handle most minor strokes and TIAs in specialized acuteoutpatient clinics47ndash11 However we do not know how acuteoutpatient specialist care compares with in-hospital strokeunit care1213 It is debated how to most efficiently organizeservices for patients with minor strokeTIA1214ndash16 and use ofhospitalization seems widespread1718 Hospitalization conferstheoretical benefits over urgent outpatient clinic referral in-cluding monitoring of the patients and rapid access to re-vascularization but these benefits are offset by potentialdrawbacks of hospitalization together with potential overuseof hospital resources12141920 The risk of a recurrent strokeremains the main concern of outpatient treatment and aninnovative approach may be a hybrid that combines benefitsfrom both strategies14

In 2012 an acute outpatient clinic for patients with suspectedminor strokeTIA opened at Aarhus University HospitalDenmark following centralization of acute stroke careservices2122 In the clinic a specialized neurovascular teamperforms a complete diagnostic workup and treatment thesame day the patient is referred and assesses the risk of pa-tients with strokeTIA to identify those at high risk of a re-current stroke and hence eligible for admission to a regularstroke ward

MethodsStandard Protocol Approvals Registrationsand Patient ConsentsThe study was approved by the Danish Data ProtectionAgency (2012-58-006) the Danish Patient Safety Authority(3-3013-18781) and the Danish Clinical Registries UnderDanish law registry-based studies require no ethics approvalor patient consent The Danish Patient Safety permittedcollection of information from the patient records withoutpatientsrsquo consent

Primary Research Question and Classificationof Level of EvidenceThe primary research question was as follows Is an outpatientclinic setup for patients with minor strokeTIA combinedwith admission of selected high risk patients effective and safecompared to stroke unit admission of all patients with minorstrokeTIA

This study provides Class III evidence that an outpatient clinicsetup for minor strokeTIA with subsequent admission ofpatients at high risk of a recurrent stroke yields shorter acutehospital stay lower readmission rates and better quality thanhospitalization in stroke units

Outpatient Clinic Setup and Risk AssessmentThe outpatient clinic at Aarhus University Hospital Den-mark is part of 1 of the 2 high-volume designated strokecenters that receive all patients with acute stroke and TIAfrom the Central Denmark Region (CDR) (13 million in-habitants)22 The outpatient clinic is an integrated part of thestroke unit which is open 7 days a week in the daytime (8AMndash6 PM) and staffed by a specialized neurovascular seniordoctor a nurse and therapists when needed

A local stroke guideline was developed for all patients withsuspected acute stroke and TIA with symptom onset withinthe past 7 days and 48 hours respectively or accumulatedneurovascular episodes According to this guideline the pre-hospital service or general practitioners immediately called anexperienced neurologist on call 24 hours7 days to arrangeacute evaluation by stroke specialist All self-reliant patientswith suspected acute minor stroke who were not candidatesfor acute reperfusion or TIA were seen in the outpatient clinicduring opening hours At nighttime these patients were ad-mitted for immediate evaluation in the stroke unit Theemergency department was bypassed in all cases Figure 1shows the details of the patient flow

Diagnostic workup in the outpatient clinic included a brainscan (standard MRI) ultrasound of carotid arteries (if in-dicated ultrasound CT angiography or magnetic resonanceangiography of the intracranial vessels) blood samplesECG and evaluation of lifestyle factors If a Holter monitorwas indicated the patient was provided one as an outpatientand could return the equipment by mail If the patientneeded echocardiography he or she was referred to theDepartment of Cardiology All patients in need of outpatientrehabilitation had a full evaluation by a physiotherapist andan occupational therapist before returning home and had aplan for outpatient rehabilitation by community servicePatients in whom thrombolysis or thrombectomy was in-dicated were handed over to staff in the stroke unit as theoutpatient clinic was part of the acute stroke center andlocated in the same facilities

After the outpatient evaluation we systematically assessed riskin all patients diagnosed with stroke or TIA to distinguish

GlossaryCDR = Central Denmark RegionCI = confidence intervalDSR =Danish Stroke RegistryDWI = diffusion-weighted imagingHR = hazard ratio ICH = intracerebral hemorrhage LOSR = length of stay ratioNIHSS = NIH Stroke Scale RR = risk ratioSSS = Scandinavian Stroke Scale

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1097

between those at low risk of a recurrent stroke within 7 dayswho could safely be sent directly home from those at high riskof a recurrent stroke who may need to be admitted to thestroke ward For risk assessment we used a tool developed bythe neurovascular team The tool included the ABCD2score23ndash25 and results of imaging of the brain and precranial orintracranial arteries2627 together with other risk factors forexample cardioembolic risk factors At the neurologistrsquos dis-cretion other elements like psychosocial issues were takeninto account For patients with stroke the tool included theNIH Stroke Scale (NIHSS) score28 instead of the ABCD2score The risk assessment was a guiding tool only the finaldecision to admit the patient to the stroke unit was made atthe specialized neurovascular senior doctorrsquos discretion

If the patient with strokeTIA was sent home directly fromthe outpatient clinic we rang the patient on day 7 to identifyany new vascular events

In patients without a cerebrovascular diagnosis staff in theoutpatient clinic finished the diagnostic workup performingother relevant tests or procedures for example lumbarpuncture or other neuroradiologic examinations The patientwas admitted to the general neurologic ward for further in-vestigations only in case of a suspected or confirmed majorneurologic disease (eg tumor) Furthermore we assessedpatients with non-neurologic disease to determine whetherthey needed admission at another hospital department orcould be sent home to follow up with a general practitioner

Study DesignThis was a cohort study The effects of the outpatient clinicsetup in patients with minor strokeTIA were investigated bycomparing outcomes to those of matched controls

Study Cohort and Matched ControlsThe outpatient clinic cohort included all patients with sus-pected minor stroke or TIA evaluated in the acute neuro-vascular outpatient clinic at Aarhus University HospitalDenmark between 1 September 2013 and 31 August 2014including patients who ended up being admitted at the strokeward or converted to an IV thrombolysis pathway

Patients with minor strokes were compared to 2 referencepopulations including historic and contemporary matchedhospitalized controls respectively Patients with TIA werecompared to contemporary matched hospitalized controlsonly as historic controls were not available in the DanishStroke Registry (DSR)

Figure 2 shows the details of how we generated the matchedhistoric stroke cohort from the same hospital between May2011 and April 2012 that is before the outpatient clinic wasestablished and the contemporary stroke and TIA cohortfrom a comparable stroke center at a university hospital in theCapital Region (Glostrup) without an acute outpatient clinicservice Before matching the 2 cohorts we restricted the pa-tient populations to patients with reliable data on length ofacute hospital stay known vital status and complete

Figure 1 Details of the Triage of Patients With Suspected StrokeTIA (Symptom Onset lt7 Days48 Hours) in the CentralDenmark Region in the Study Period

EMS = emergency medical services GP = general practitioner

e1098 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

information on matching criteria age (groups 0ndash18 19ndash5051ndash65 66ndash80 80+ years) sex stroke severity (ScandinavianStroke Scale [SSS] in groups 0ndash14 15ndash29 30ndash44 45ndash58)treatment with thrombolysis including door-to-needle time(under or above 1 hour) and subtype of diagnosis (ischemicstroke ICH or TIA) The matching was done 11 and pa-tients from the reference cohorts could be used more thanonce

OutcomesThe complete study cohort was investigated with regards tothe distribution of ldquoneurovascular diagnosisrdquo ldquoneurologic di-agnosisrdquo and ldquonon-neurologic diagnosisrdquo and the mostcommon diagnoses within each subgroup were identifiedFurthermore we estimated the rates of patients with sub-sequent admission at the stroke ward In patients with is-chemic strokeTIA we estimated the rates of low risk andhigh risk according to the risk assessment tool The rate ofrecurrent vascular events within 7 days was examined in pa-tients with stroke or TIA discharged directly from the out-patient clinic

The effects of the outpatient clinic setup were investigated inpatients with stroke using the following nonprioritized out-come measures length of acute and total (including in-hospital rehabilitation) hospital stay all-cause bed days hos-pital readmissions after discharge (0ndash30 and 31ndash365 days)mortality (0ndash30 and 0ndash365 days) and quality of care (10individual key process performance measures)

The patients with TIA were evaluated according to the sameoutcome measures except for readmissions and all-cause beddays as these data were not available and only 4 of the in-dividual key process performance measures were found to berelevant for TIA and were therefore included

We defined 2 composite measures of process quality of carethe ldquoall or nonerdquo measure was defined as the proportion ofminor strokeTIA episodes where all eligible measures werefulfilled for the individual patient whereas the ldquoopportunity-basedrdquo score was defined as the overall proportion of fulfilledrelevant performance measures for each patient The latterscore was calculated by dividing the total number of receivedprocesses for each patient by the total number of processes forwhich the patient was considered eligible

We recorded the number of patients with TIA with acutelesions on MRI (diffusion-weighted imaging [DWI]ndashpositive) or infarction on CT

DefinitionsA suspected acute stroke (or TIA) was defined as acute focalneurologic deficits (or a history of such disease) with no otherobvious reasons than a possible cerebrovascular event Strokewas defined as symptoms of vascular origin lasting 24 hours orlonger or leading to death and included ischemic strokes andintracerebral hemorrhages (ICH) TIA was defined as a tran-sient episode of neurologic symptoms of ischemic origin lastingless than 24 hours disregardingMRI confirmation but TIA didnot include related syndromes for example amaurosis fugax

Admission length was counted as half rather than whole dayswhen a patient died or went home from the hospital on theday of evaluation To ensure that the total length of thehospital stay included rehabilitation irrespective of local or-ganizational differences admissions on the day following theend of the acute stay were calculated as part of the total stay

All-cause bed days were defined as the total number of days spentin the hospital within the first year including the total hospital stayof the initial stroke admission To ensure that outpatient visits

Figure 2 Details of Generation of the Matched Historic Stroke Cohort and the Matched Contemporary Stroke and TIACohorts

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1099

were not counted as part of all-cause bed days only new admis-sions (acutenonacute) of ge24 hours were included

To be considered a readmission at least 1 day was requiredbetween the day of the termination of the total stay and thenext admission date Only acute admissions ge24 hours wereincluded hence no outpatient visits were considered read-missions All admissions due to carotid artery surgery wereexcluded as readmissions because they were considered partof the acute stroke care

To be classified as being at low risk patients with TIA wouldhave to have no acute ischemia on MRI (DWIinfarction onCT) or an ABCD2 score le3 and patients with stroke anNIHSS score lt5 Furthermore patients with TIA and strokeshould have no symptomatic stenosis (ge50) of the carotidarteries no symptomatic stenosis (verified or suspected) ofthe intracranial vessels no major cardioembolic risk factorsand no other complications for which an inpatient course wasneeded

Data SourcesA local registry holds information on diagnosis for all patients(vascular or nonvascular) including imaging and risk assess-ment and it includes the mandatory process and outcomeindicators collected in the DSR2930 This local registry in-cludes results of 7-day follow-up Local registration wascompleted on a daily basis by the clinicrsquos neurovascular teamThe electronic medical records were searched in case ofmissing information on risk assessment or vascular eventswithin 7 days

We obtained data from the DSR (baseline characteristicslength of acute hospital stay and process performance mea-sures) to characterize strokes and TIA from the study cohortand the matched cohorts Reporting to the DSR is mandatoryfor all acute strokes (ge18 years of age) seen at hospitals Giventhe Danish tradition for seeing almost all patients with acutestroke symptoms in the hospital almost all patients with acute

stroke in Denmark are registered31 The completeness ofstroke event registration in the DSR exceeds 9032

The Danish National Patient Register provided information onsubsequent hospitalizations including transfers from the acutestroke unit to in-hospital rehabilitation and readmissions33

The Danish Civil Registration System provided informationon patientsrsquo vital status34 This system assigns a unique per-sonal identification number to all Danish citizens and we usedthis to link information recorded in different databases

Statistical AnalysisWe used a generalized linear model with a log-link and gammadistribution family to compare the length of stay ratios(LOSRs)

For readmissions we compared hazard ratios (HRs) usingmultivariable Cox regression encountering the time of a po-tential readmission or death and analyzed mortality outcomesaccordingly We also calculated adjusted and unadjusted HRs

We analyzed clinical guideline-recommended process per-formance measures using binomial regression Unadjustedrisk ratios (RRs) were calculated We included only caseswhere the health professionals caring for the individual patienthad judged the specific process measure to be relevant

By using multivariable models we adjusted for age (contin-uous variable) living arrangement previous stroke diabetesatrial fibrillation hypertension smoking habits alcohol useand stroke severity (SSS as a continuous variable) Unknownor missing information on living arrangement previousstroke diabetes atrial fibrillation hypertension smokinghabits and alcohol use was encoded by an indicator variableand included in the adjusted analyses Confidence intervals(CIs) were based on robust standard errors

We used the Stata 130 package (StataCorp LP CollegeStation TX) for all analyses

Data AvailabilityAccording toDanish law it is not possible to provide public accessto a dataset that is based on linkage of data fromnationwide publicregistries Access to Danish registry data can be granted to in-dividual researchers only upon seeking approval from theNationalAgency forData ProtectionWe therefore cannot place the datasetin a public repository However pooling of aggregated data ispossible and would be of interest to the research group

ResultsThe outpatient clinic cohort comprised 1076 patients (figure2) of whom 253 (235) were subsequently admitted to thestroke unit A neurovascular diagnosis was given in 510 of thepatients (474) Of these 215 had a stroke 171 had TIA

Table 1 Risk Category on all Patients With IschemicStroke and TIA From the Outpatient Clinic Cohortand Information on Any Subsequent Admissionto the Stroke Ward n ()

Ischemic stroke and TIAn = 382

High-riskcategory n = 167

Low-risk categoryn = 215

Admitted to stroke ward 122 (731) 45 (209)

Stayed as outpatient 45 (269) 170 (791)

7-day follow-uprecurrent eventsa

1 (22)b 1 (06)c

a Results of 7-day follow-up for recurrent vascular events (recurrent TIAstroke or acute myocardial infarction) in the outpatients without admissionto stroke wardb Recurrent TIAc Recurrent ischemic stroke

e1100 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

Table 2 Characteristics of the Patients From the Matched Cohorts Outpatient Stroke Cohort 1 (OSC1) vs Historic StrokeCohort (HSC) Outpatient Stroke Cohort 2 (OSC2) vs Contemporary Stroke Cohort (CSC) and Outpatient TIACohort (OTC) vs Contemporary TIA Cohort (CTC)

OSC1 HSC OSC2 CSC OTC CTC

Patients n 191 191 194 194 153 153

Age y mean (SD) 658 (118) 663 (132) 655 (120) 660 (129) 663 (132) 674 (133)

Sex female n () 76 (398) 76 (398) 79 (407) 79 (407) 69 (451) 69 (451)

Severity SSS score median (IQR) 56 (3) 55 (9) 56 (3) 56 (5) 58 (0) 58 (2)

Thrombolysis n () 3 (16) 3 (16) 3 (16) 3 (16) 0 (00) 0 (00)

Days to evaluation median (IQR) 1 (2) 1 (1) 1 (2) 1 (2) 0 (1) 0 (0)

Unknownmissing n () 0 (00) 2 (10) 0 (00) 9 (46) 0 (00) 3 (20)

Subtype n ()

Intracerebral hemorrhage 4 (21) 4 (21) 3 (16) 3 (16) NA NA

Ischemic stroke 187 (979) 187 (979) 191 (985) 191 (985) NA NA

TIA NA NA NA NA 153 (1000) 153 (1000)

Former stroke n ()

Yes 45 (236) 44 (230) 45 (232) 45 (232) 18 (118) 38 (248)

No 146 (764) 146 (764) 149 (768) 148 (763) 135 (882) 115 (752)

Unknownmissing 0 (00) 1 (05) 0 (00) 1 (05) 0 (00) 0 (00)

Hypertension n ()

Yes 115 (602) 104 (545) 118 (608) 106 (546) 72 (471) 76 (497)

No 75 (393) 82 (429) 75 (387) 85 (438) 80 (523) 77 (503)

Unknownmissing 1 (05) 5 (26) 1 (05) 3 (155) 1 (07) 0 (00)

Diabetes n ()

Yes 23 (120) 21 (110) 25 (130) 26 (134) 20 (131) 27 (177)

No 168 (880) 167 (874) 169 (871) 167 (861) 132 (863) 126 (824)

Unknownmissing 0 (00) 3 (16) 0 (00) 1 (05) 1 (07) 0 (00)

Atrial fibrillation n ()

Yes 11 (58) 26 (136) 11 (57) 28 (144) 15 (98) 16 (105)

No 180 (942) 163 (853) 183 (943) 163 (840) 138 (902) 135 (882)

Unknownmissing 0 (00) 2 (11) 0 (00) 3 (16) 0 (00) 2 (13)

Alcohol use n ()

le14 (F)21 (M) units per week 161 (843) 158 (827) 163 (840) 154 (794) 135 (882) 130 (850)

gt14 (F)21 (M) units per week 29 (152) 29 (152) 30 (155) 32 (165) 17 (111) 18 (118)

Unknownmissing 1 (05) 4 (21) 1 (05) 8 (41) 1 (07) 5 (33)

Smoking n ()

Daily 86 (4503) 74 (387) 88 (454) 69 (356) 29 (190) 32 (209)

Former 56 (2932) 56 (293) 56 (289) 51 (263) 51 (333) 57 (373)

Never 49 (2565) 61 (319) 50 (258) 61 (314) 71 (464) 53 (346)

Unknownmissing 0 (000) 0 (000) 0 (00) 13 (67) 2 (13) 11 (72)

Continued

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1101

and 124 had another neurovascular diagnosis Ninety-four(437) of the patients with stroke and 121 (708) of thepatients with TIA were sent directly home from the outpatientclinic of these 170 (791) were considered low-risk patients(table 1) Of the 690 patients with another neurovasculardiagnosis (n = 124) (not stroke or TIA) or a non-neurovascular diagnosis (n = 566) 608 (881) were man-aged without subsequent admission to the stroke ward

Of the 124 patients with another neurovascular diagnosis the 3most common diagnoses were amaurosis fugaxretinal arteryocclusion (n = 65) recrudescence of prior stroke (n = 35) andsubdural hemorrhage (n = 6) A large percentage (436) wereregistered with another neurologic diagnosis (n = 469) and the3 most common diagnosis among these were disturbances ofskin sensation (n = 112) migraine (n = 62) and dizziness (n =57) A non-neurologic diagnosis was given in only 97 (9) ofthe patients from the outpatient clinic cohort and the 3 mostcommon diagnoses were syncope and collapse (n = 21)noncentral disorders of vestibular function (n = 12) and in-fections (eg cystitis sinusitis meningitis) (n = 9)

We obtained complete risk assessment score data on all 382patients with ischemic stroke and TIA from the outpatientclinic cohort Of the 170 patients at low risk handled as out-patients without subsequent admission to the stroke unit onlyone had a recurrent stroke (06) within the first 7 days afterthe outpatient visit (table 1)

Three patients with ischemic stroke from the study cohortreceived thrombolysis all 3 were treated within 1 hour fromarrival to the outpatient clinic

Of the patients with TIA 33 (193) had an acute lesion onMRI (DWI-positive) or an infarction on CT whereas this wasthe case for 187 (886) of the patients with ischemic stroke

Approximately 90 of the patients with stroke and TIA wereavailable for comparison with the matched reference pop-ulations after we had excluded those who were not eligible ormatched Figure 2 shows details of generation of the matched

historic stroke cohort and the matched contemporary strokeand TIA cohorts

The baseline characteristics of the matched stroke and TIA co-horts are shown in table 2 Overall the groups were well bal-anced with regard to age (strokeTIA asymp66ndash67 years) and strokeseverity (stroke asymp55ndash56 of 58 points on the SSS) The mediannumber of days from symptom onset to admission was the samewith a median of 1 day in the stroke cohorts and 0 days in theTIA cohorts

Patients with stroke from the study cohort (n = 191) had ashorter risk-adjusted length of acute hospital stay than the his-toric stroke cohort (n = 191) (median 1 vs 3 days adjustedLOSR 049 [95 CI 033ndash071]) (table 3) Furthermore thelength of total stay including rehabilitation was shorter in thestrokes from the study cohort than in the historic cohort (me-dian 1 vs 4 days adjusted LOSR 057 [95 CI 036ndash089]) andall-cause bed days within the first year were fewer (median 2 vs 6days adjusted LOSR 067 [046ndash100]) Moreover in thiscomparison of strokes from the outpatient clinic cohort withhistoric controls readmission rates within the first 30 days afterthe initial hospital stay were lower (32 vs 116 adjusted HR023 [009ndash059]) whereas risk-adjusted readmission rates be-tween days 31 and 365 were comparable Mortality rates at day30 and day 365 were equal and low (00 vs 05 26 vs52) All or none of 10 process performance measures werehigher in the patients with stroke from the outpatient cliniccohort (843) than among patients with stroke in the historicstroke cohort (649) with an RR of 130 (115ndash147) (table 3)

The comparison of the patients with stroke from the outpatientclinic cohort (n = 194) with the patients with strokes from thematched contemporary cohort from Glostrup (n = 194)showed almost the same picture with a shorter median acutehospital stay (1 vs 4 days) fewer readmissions in the first 30days (31 vs 113) comparable mortality rates and higher allor none of 10 process performance measures (table 4)

Patients with TIA from the outpatient clinic cohort werecompared with the matched contemporary TIA cohort from

Table 2 Characteristics of the Patients From the Matched Cohorts Outpatient Stroke Cohort 1 (OSC1) vs Historic StrokeCohort (HSC) Outpatient Stroke Cohort 2 (OSC2) vs Contemporary Stroke Cohort (CSC) andOutpatient TIA Cohort(OTC) vs Contemporary TIA Cohort (CTC) (continued)

OSC1 HSC OSC2 CSC OTC CTC

Living arrangements n ()

Living with someone 125 (655) 124 (649) 127 (655) 116 (598) 104 (679) 94 (614)

Living alone 65 (340) 66 (346) 66 (340) 73 (376) 49 (320) 52 (340)

Other form 1 (05) 1 (05) 1 (05) 3 (16) 0 (00) 3 (20)

Unknownmissing 0 (00) 0 (00) 0 (00) 2 (10) 0 (00) 4 (26)

Abbreviations IQR = interquartile range SSS = Scandinavian Stroke Scale

e1102 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

Table 3 Differences in Lengths of Hospital Stay All-Cause Bed Days Readmissions Mortality and Process PerformanceMeasures in Outpatient Stroke Cohort 1 (OSC1) and the Matched Historic Stroke Cohort (HSC)

Bed days (in hospital)Outpatient stroke 1 (OSC1) n = 191215d median (IQR)

Historic stroke (HSC) n = 191d median (IQR)

OSC1 vs HSC (CI)

LOSRLOSRadjusteda

Acute stay 100 (150) 300 (400) 048(032ndash073)

049(033ndash071)

Total stay 100 (250) 400 (600) 050(032ndash077)

057(036ndash089)

All-cause bed days in 1 year 200 (700) 600 (1200) 060(042ndash087)

067(046ndash100)

ReadmissionsOutpatient stroke 1 (OSC1) n = 191215 (CI) ntotal n

Historic stroke (HSC) n = 191 (CI)ntotal n

OSC1 vs HSC

HR (CI)HRadjusteda

0ndash30 days 32 (06ndash57) 6189 116 (70ndash162) 22190 026(011ndash065)

023(009ndash059)

Admitted to stroke unit 36 (01ndash71) 4112 NA NA NA

Outpatient course only 26 (minus10-62) 277 NA NA NA

31ndash365 days 280 (216ndash345) 53189 307 (241ndash373) 58189 087(060ndash127)

087(059ndash131)

Admitted to stroke unit 268 (185ndash351) 30112 NA NA NA

Outpatient course only 299 (194ndash403) 2377 NA NA NA

MortalityOutpatient stroke 1 (OSC1) n =191215 (CI) ntotal n

Historic stroke (HSC) n = 191 (CI)ntotal n

OSC1 vs HSC

HR (CI)HRadjusteda

30 days 00 (00ndash00) 0191 05 (minus05 to 16) 1191 NA NA

365 days 26 (03ndash49) 5191 52 (20 to 84) 10191 049(017ndash143)

094(026ndash337)

Process performancemeasures

Outpatient stroke 1 (OSC1) n = 191215 (CI) ntotal n

Historic stroke (HSC) n = 191 (CI) ntotal n

OSC1 vs HSC

RR (CI)RRadjusteda

All or noneb 843 (791ndash895) 161191 649 (581ndash718) 124191 130(115ndash147)

NA

Opportunity-based score ()c

969 (957ndash981) 191191 909 (886ndash933) 191191 107(101ndash112)

NA

Antiplatelet therapy le2daysd

988 (972ndash1005) 171173 973 (947ndash999) 145149 102(102ndash102)

NA

Anticoagulation therapyle14 daysd

667 (282ndash1051) 69 1000 (1000ndash1000) 99 064(040ndash101)

NA

Brain imaging (CT or MRI)le0 daysd

984 (967ndash1002) 188191 932 (896ndash968) 178191 106(101ndash110)

NA

Imaging of the carotids le4daysd

994 (982ndash1006) 168169 914 (870ndash959) 139152 112(106ndash117)

NA

Physiotherapy le2 daysd 949 (911ndash986) 129136 895 (845ndash944) 136152 106(099ndash113)

NA

Occupational therapist le2daysd

957 (924ndash991) 135141 901 (853ndash949) 137152 106(100ndash113)

NA

Mobilization le0 daysd 974 (950ndash997) 184189 919 (880ndash959) 171186 106(101ndash111)

NA

Continued

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1103

Glostrup In patients with TIA the acute and total hospitalstays were significantly shorter than in the matched contem-porary cohort of patients with TIA The length of the acutestay was a median of 05 days vs 2 days Mortality rates at day30 and day 365 were comparable in the 2 TIA cohorts (00vs 00 20 vs 59) All or none of 4 process performancemeasures were higher in the patients with TIA from theoutpatient clinic cohort (967) than in the contemporaryTIA patients (876) (table 5)

DiscussionThis prospective cohort study of patients seen in an outpatientclinic for acute minor stroke and TIA using subsequent ad-mission of high-risk patients shows that these patients have ashorter hospital stay lower rate of readmissions at 30 days andhigher quality of care than patients in matched historic andcontemporary cohorts without a similar outpatient service

Substantially reducing the length of hospital stay may have theuntoward consequence of increasing the overall readmissionrate which is a frequently used measure of quality andsafety3536 of care although there is some controversy as to howreadmissions should be interpreted37 However we also ob-served a lower rate of risk-adjusted readmissions within the first30 days among patients with stroke in the outpatient cliniccohort This may be due to overall higher quality of care asevidenced by a decline in the rate of recurrent vascular eventsand other potential complications38 Another driver of thisreduction could be the lesser risk of a hospital-acquired in-fection39 Furthermore almost half of the patients with strokein the outpatient clinic cohort (without an inpatient course)were offered a 7-day follow-up by telephone which was notstandard in hospitalized stroke cohorts and this initiative mayhave prevented readmissions but also limits direct comparisons

Readmission rates among these outpatients (with or without7-day follow-up) were low and similar indicating that the effecton the results may have been inconsiderable

Another potential concern with the shorter length of stay isrecurrent neurovascular events at home the risk of which ishighest during the first days112 Tominimize this problem weaimed to identify and hospitalize patients at high risk of re-current episodes and hence extended their length of hospitalstay14 To qualify the clinical decision to do so we developed arisk assessment tool using the ABCD2 score combined withimaging26 and other essential risk factors for recurrent epi-sodes The ABCD2 score and the later addition of vesselstatus and brain imaging were originally used to select patientsin need of rapid referral to a neurovascular specialist40 buthere we used the tool to qualify the decision of need forhospitalization This approach seemed acceptable and safe asthe overall rate of recurrent vascular episodes in patients whowere treated in the outpatient clinic without admission waslow (09) only 06 of low-risk patients and the recurrencerates were lower than previously reported14142

We were not able to calculate a reliable rate of recurrent strokein the hospitalized patients of the study cohort or in the ref-erence cohorts as new events in the early phase are not regis-tered in the DSR and we did not perform a 7-day follow-up

The significantly higher fulfillment of process performancemeasures in patients with minor stroke and TIA from theoutpatient clinic cohort within a defined time frame wassurprising Although the exact driver of this remains unknownwe speculate that it may stem from the standardized setupwith rapid asses to MRI ultrasound and specialist evaluation

Considering all of the patients with a final diagnosis of strokeand TIA from the entire stroke center at Aarhus University

Table 3 Differences in Lengths of Hospital Stay All-Cause Bed Days Readmissions Mortality and Process PerformanceMeasures in Outpatient Stroke Cohort 1 (OSC1) and the Matched Historic Stroke Cohort (HSC) (continued)

Bed days (in hospital)Outpatient stroke 1 (OSC1) n = 191215d median (IQR)

Historic stroke (HSC) n = 191d median (IQR)

OSC1 vs HSC (CI)

LOSRLOSRadjusteda

Nutrition (assessment) le2daysd

947 (915ndash979) 179189 911 (870ndash951) 173190 104(098ndash110)

NA

Indirect swallow test le2daysd

968 (943ndash993) 183189 887 (841ndash933) 165186 109(103ndash116)

NA

Direct swallow test le2daysd

963 (935ndash990) 180187 892 (848ndash937) 166186 108(102ndash114)

NA

Abbreviations CI = confidence interval HR = hazard ratio IQR = interquartile range LOSR = length of stay ratio RR = risk ratioa Adjusted for age (continuous variable) stroke severity (Scandinavian Stroke Scale continuous variable) living arrangements previous strokes diabetesatrial fibrillation smoking alcohol and hypertensionb All or none of the 10 process performance measures defined as the proportion of minor strokeTIA episodes where all eligible measures were fulfilled forthe individual patientc Opportunity-based score defined as the overall proportion of fulfilled relevant performance measures for each patientd Included in ball or none and in copportunity-based score

e1104 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

Table 4 Differences in Lengths of Hospital Stay All-Cause Bed Days Readmissions Mortality and Process PerformanceMeasures in Outpatient Stroke Cohort 2 (OSC2) and the Matched Contemporary Stroke Cohort (CSC)

Bed days (in hospital)Outpatient stroke 2 (OSC2) n = 194215d median (IQR)

Contemporary (CSC) n = 194d median (IQR)

OSC2 vs CSC

LOSR (CI)LOSRadjusteda

Acute stay 100 (150) 400 (400) 032(021ndash048)

037(025ndash055)

Total stay 100 (250) 400 (425) 074(048ndash112)

072(049ndash107)

All-cause bed days in 1 year 200 (700) 600 (1025) 076(054ndash107)

095(066ndash138)

ReadmissionsOutpatient stroke 2 (OSC2) n = 194215 (CI) ntotal n

Contemporary (CSC) n = 194 (CI)ntotal n

OSC2 vs CSC

HR (CI)HRadjusteda

0ndash30 days 31 (06ndash56) 6192 113 (68ndash158) 22194 027(011ndash065)

037(014ndash095)

Admitted to stroke unit 35 (01ndash70) 4113 NA NA NA

Outpatient course only 25 (minus10-61) 279 NA NA NA

31ndash365 days 276 (212ndash340) 53192 354 (286ndash422) 68192 071(049ndash101)

073(050ndash107)

Admitted to stroke unit 257 (175ndash338) 29113 NA NA NA

Outpatient course only 304 (200ndash407) 2479 NA NA NA

MortalityOutpatient stroke 2 (OSC2) n = 194215 (CI) ntotal n

Contemporary (CSC) n = 194 (CI)ntotal n

OSC2 vs CSC

HR (CI)HRadjusteda

30 days 00 (00ndash00) 0194 00 (00ndash00) 0194 NA NA

365 days 26 (33ndash48) 57 (24ndash90) 11194 045(015ndash128)

063(020ndash198)

Process performancemeasures

Outpatient stroke 2 (OSC2) n = 194215 (CI) ntotal n

Contemporary (CSC) n = 194 (CI) ntotal n

OSC2 vs CSC

RR (CI)RRadjusteda

All or noneb 845 (794ndash897) 164194 716 (653ndash780) 139194 118(106ndash131)

NA

Opportunity-based score()c

970 (958ndash982) 194194 907 (880ndash933) 194194 107(102ndash113)

NA

Antiplatelet therapy le2daysd

989 (973ndash1004) 175177 980 (958ndash1003) 149152 101(101ndash101)

NA

Anticoagulation therapyle14 daysd

667 (282ndash1051) 69 1000 (1000ndash1000) 2323 064(040ndash101)

NA

Brain imaging (CT or MRI)le0 daysd

985 (967ndash1002) 191194 881 (835ndash927) 170193 112(106ndash118)

NA

Imaging of the carotids le4daysd

994 (983ndash1006) 172173 968 (942ndash993) 179185 103(103ndash103)

NA

Physiotherapy le2 daysd 949 (912ndash986) 131138 929 (881ndash977) 105113 102(096ndash109)

NA

Occupational therapist le2daysd

958 (925ndash991) 137143 940 (897ndash984) 110117 102(096ndash108)

NA

Mobilization le0 daysd 974 (951ndash997) 187192 914 (872ndash956) 159174 107(101ndash112)

NA

Nutrition (assessment) le2daysd

948 (916ndash980) 182192 901 (855ndash946) 154171 105(099ndash112)

NA

Continued

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1105

Hospital approximately 16 of the patients with stroke and34 of the patients with TIA went to the outpatient clinic inthe study period (based on reported patients in 2014 to DSR30)but we were unable to investigate whether according to the localinstruction more patients were eligible for the outpatient clinicHowever this is likely to have reduced costs per patient as shorteracute hospital stays for patients with stroke reduce hospital costsoverall43 and the outpatient setup is probably also more costeffective81544 Furthermore the reduction in the rate of read-missions is likely to contribute further to cost reduction45 Nev-ertheless tomake final conclusions on the financial implications aformal economic evaluation is needed

Centralization of stroke services resulting in shorter hospitalstays is associated with high levels of patient and relative sat-isfaction and we speculate that this outpatient setup similarlyled to increased satisfaction among patients and relatives46

All patients with suspected acute minor stroke and TIA werereferred directly to the outpatient clinic for diagnostic workupfrom emergency medical services and general practitioners Aconsiderable number were given a non-neurovascular di-agnosis (asymp53) A high rate of minor stroke and TIA mis-diagnosis (asymp60) has been documented in nonspecializedsettings47 The result of this is that patients forgo the benefitsof timely evaluation and early treatment initiation or aretreated unnecessarily Direct referral saves many people fromthe debilitating effects of misdiagnosis47

An MRI scan of the brain was standard in the diagnosticworkup and could have contributed to the high rate of non-neurovascular diagnoses as MRI is more sensitive to acutesmaller ischemic lesions than a CT scan48 and helpful inrejecting a strokeTIA suspicion

A strength of this study is that it included all patients seen in theoutpatient clinic for a period of 1 year and that a high rate ofapproximately 90 of the patients with stroke or TIA wereavailable for comparison with thematched reference populations

A limitation of the nonrandomized study design is that itcarries a risk of confounding which might have affected thelength of hospital stay all-cause bed days rate of read-missions and mortality but it is unlikely to have affected thequality of care reflected in key process performance indicatorsdue to very explicit inclusion and exclusion criteria used forthese indicators By matching the cohorts on essential criteriaand adjusting data we minimized the risk of confoundingFurthermore we used 2 different reference cohorts to ex-amine the effect which strengthened the design

The study period began 16 months after opening of theoutpatient clinic and hence the comparison with the historiccontrols may be subject to confounding by an underlyingcalendar timendashrelated trend of improvements in stroke careWe chose this study period because we aimed to examine thefully implemented setup and therefore deliberately did notinclude the period immediately after the launch of the re-organization Furthermore historic controls for patients withTIA were lacking as registration of patients with TIA in theDSR was not implemented until mid-2013

The matched cohort from a contemporary period fromanother hospital was not exposed to these general timetrends in care but was vulnerable to local differences be-tween the hospitals that could potentially affect the resultsTo minimize this risk we used patients from a comparableuniversity hospital without an acute outpatient clinic ina region that is sociodemographically and healthwisefairly similar49 and with the same standards of stroke careaccording to the DSR30

A randomized controlled experiment where all self-reliant pa-tients suspected of minor stroke and TIA were randomized toeither the outpatient clinic or direct hospitalization would haveminimized the risk of bias further andwould inmanyways be thepreferred design to study the outpatient setup This was not anoption as the implementation of outpatient clinics was part of thepolitically decided reorganization of the acute stroke services in

Table 4 Differences in Lengths of Hospital Stay All-Cause Bed Days Readmissions Mortality and Process PerformanceMeasures in Outpatient Stroke Cohort 2 (OSC2) and the Matched Contemporary Stroke Cohort (CSC) (continued)

Bed days (in hospital)Outpatient stroke 2 (OSC2) n = 194215d median (IQR)

Contemporary (CSC) n = 194d median (IQR)

OSC2 vs CSC

LOSR (CI)LOSRadjusteda

Indirect swallow test le2daysd

969 (944ndash994) 186192 849 (795ndash903) 146172 114(107ndash122)

NA

Direct swallow test le2daysd

963 (936ndash990) 183190 849 (794ndash904) 141166 113(106ndash122)

NA

Abbreviations CI = confidence interval HR = hazard ratio IQR = interquartile range LOSR = length of stay ratio RR = risk ratioa Adjusted for age (continuous variable) stroke severity (Scandinavian Stroke Scale continuous variable) living arrangements previous strokes diabetesatrial fibrillation smoking alcohol and hypertensionb All or none of the 10 process performancemeasures defined as the proportion ofminor strokeTIA episodeswhere all eligiblemeasureswere fulfilled for theindividual patientc Opportunity-based score defined as the overall proportion of fulfilled relevant performance measures for each patientd Included in ball or none and in copportunity-based score

e1106 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

the CDR and a real-world cohort study using matched cohortstherefore became our design choice50

Overall the investigated acute outpatient clinic setup forminor stroke and TIA was a hybrid model where special-ized neurovascular clinicians diagnosed and assessed therisk of recurrent vascular events to support triage forsubsequent admission to the stroke ward The model wasbeneficial in terms of reduced length of hospital stayhigher quality of stroke care and reduced 30-day read-mission rates compared to historic and contemporarycontrols The triage appears safe with a low rate of re-current vascular events within the first week after returninghome The study was limited by the nonrandomized designas differences among the study cohorts could affect thecomparisons

Study FundingThis study was supported by the University of Aarhus Den-mark the Lundbeck Foundation Denmark and the LaerdalFoundation Norway The funders had no role in the designand conduct of the study collection management analysisand interpretation of the data preparation review and ap-proval of the manuscript or the decision to submit themanuscript for publication

DisclosureS Hastrup has received a research grant from the University ofAarhus and the Lundbeck Foundation SP Johnsen has re-ceived speaker honoraria from Bayer Bristol-Myers SquibbPfizer and Sanofi has acted as a consultant for Bayer Bristol-Myers Squibb Pfizer and Sanofi and has received researchgrants from Bristol-Myers Squibb and Pfizer M Jensen re-ports no disclosures P vonWeitzel-Mudersbach has receivedtravel grants from Rapid-Medical Stryker and Boehringer-Ingelheim CZ Simonsen has received a research grant fromNovo Nordisk Foundation N Hjort and AT Moslashller reportno disclosures T Harbo has received speaker honoraria fromCSL Behring MS Poulsen reports no disclosures HKIversen served on the scientific advisory board for Amgen ABBristol-Myers Squibb Boehringer-Ingelheim and Bayer DDamgaard served on scientific advisory boards for AmgenAstra Zeneca Bayer and Boehringer-Ingelheim and has re-ceived speaker honoraria from Amgen Bayer Boehringer-Ingelheim Bristol Myers-Squibb MSD and Pfizer GAndersen has received speaker honoraria from Boehringer-Ingelheim Go to NeurologyorgN for full disclosures

Publication HistoryReceived by Neurology April 17 2020 Accepted in final formOctober 21 2020

Table 5 Differences in Lengths of Hospital Stay Mortality and Process Performance Measures in the Outpatient TIACohort (OTC) and the Matched Contemporary TIA Cohort (CTC)

Bed days (in hospital) OTC n = 153171 d median (IQR) CTC n = 153 d median (IQR)

OTC vs CTC

LOSR (CI) LOSR adjusteda

Acute stay 050 (050) 200 (200) 035 (029ndash043) 037 (030ndash045)

Total stay 050 (050) 200 (300) 036 (028ndash045) 037 (029ndash047)

Mortality OTC n = 153171 (CI) ntotal n CTC n = 153 (CI) ntotal n

OTC vs CTC

HR (CI) HR adjusteda

30 days 00 (00ndash00) 0153 00 (00ndash00) 0153 NA NA

365 days 20 (minus03-42) 3153 59 (21ndash97) 9153 032 (009ndash119) 031 (006ndash162)

Process performance measures OTC n = 153171 (CI) ntotal n CTC n = 153 (CI) ntotal n

OTC vs CTC

RR (CI) RR adjusteda

All or noneb 967 (939ndash996) 148153 876 (823ndash929) 134153 110 (103ndash118) NA

Opportunity-based score ()c 983 (967ndash998) 153153 958 (939ndash976) 153153 103 (099ndash107) NA

Antiplatelet therapy le2 daysd 985 (965ndash1006) 134136 1000 (1000ndash1000) 129129 098 (098ndash098) NA

Anticoagulation therapy le14 daysd 933 (790ndash1076) 1415 1000 (1000ndash1000) 1111 089 (078ndash102) NA

Brain imaging (CT or MRI) le 0 daysd 974 (948ndash999) 149153 893 (843ndash943) 134150 109 (103ndash116) NA

Imaging of carotids le4 daysd 993 (979ndash1007) 143144 978 (954ndash1003) 135138 102 (102ndash102) NA

Abbreviations CI = confidence interval HR = hazard ratio IQR = interquartile range LOSR = length of stay ratio RR = risk ratioa Adjusted for age (continuous variable) stroke severity (Scandinavian Stroke Scale continuous variable) living arrangements previous strokes diabetesatrial fibrillation smoking alcohol and hypertensionb All or none of the 4 process performancemeasures defined as the proportion ofminor strokeTIA episodeswhere all eligiblemeasures were fulfilled for theindividual patientc Opportunity-based score defined as the overall proportion of fulfilled relevant performance measures for each patientd Included in ball or none and in copportunity-based score

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1107

References1 Coull AJ Lovett JK Rothwell PM Population based study of early risk of stroke after

transient ischaemic attack or minor stroke implications for public education andorganisation of services BMJ 2004328326

2 Rothwell PM Warlow CP Timing of TIAs preceding stroke time window for pre-vention is very short Neurology 200564817ndash820

3 Rothwell PM Giles MF Chandratheva A et al Effect of urgent treatment oftransient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS

study) a prospective population-based sequential comparison Lancet 20073701432ndash1442

4 Lavallee PC Meseguer E Abboud H et al A transient ischaemic attack clinic withround-the-clock access (SOS-TIA) feasibility and effects Lancet Neurol 20076953ndash960

5 Stroke Unit Trialists Organised inpatient (stroke unit) care for stroke CochraneDatabase Syst Rev 2007CD000197

6 Cadilhac DA Kim J Lannin NA et al Better outcomes for hospitalized patients withTIA when in stroke units an observational study Neurology 2016862042ndash2048

7 von Weitzel-Mudersbach P Johnsen SP Andersen G Low risk of vascular eventsfollowing urgent treatment of transient ischaemic attack the Aarhus TIA study Eur JNeurol 2011181285ndash1290

8 OrsquoBrien E Priglinger ML Bertmar C et al Rapid access point of care clinic fortransient ischemic attacks and minor strokes J Clin Neurosci 201623106ndash110

9 Paul NL Koton S Simoni M Geraghty OC Luengo-Fernandez R Rothwell PMFeasibility safety and cost of outpatient management of acute minor ischaemic strokea population-based study J Neurol Neurosurg Psychiatry 201384356ndash361

10 Sanders LM Srikanth VK Jolley DJ et al Monash transient ischemic attack triagingtreatment safety of a transient ischemic attack mechanism-based outpatient model ofcare Stroke 2012432936ndash2941

11 Ranta A Barber PA Transient ischemic attack service provision a review of availableservice models Neurology 201686947ndash953

12 Joundi RA Saposnik G Organized outpatient care of patients with transient ischemicattack and minor stroke Semin Neurol 201737383ndash390

13 Ranta A Alderazi YJ The importance of specialized stroke care for patients with TIANeurology 2016862030ndash2031

14 Molina CA SelimMM Hospital admission after transient ischemic attack unmaskingwolves in sheeprsquos clothing Stroke 2012431450ndash1451

15 Joshi JK Ouyang B Prabhakaran S Should TIA patients be hospitalized or referred toa same-day clinic a decision analysis Neurology 2011772082ndash2088

16 Donnan GA Davis SM Hill MD Gladstone DJ Patients with transient ischemicattack or minor stroke should be admitted to hospital for Stroke 2006371137ndash1138

17 Webb A Heldner MR Aguiar de Sousa D et al Availability of secondary preventionservices after stroke in Europe an ESOSAFE survey of national scientific societiesand stroke experts Eur Stroke J 20194110ndash118

18 George BP Doyle SJ Albert GP et al Interfacility transfers for US ischemic strokeand TIA 2006-2014 Neurology 201890e1561ndashe1569

19 Cucchiara BL Kasner SE All patients should be admitted to the hospital after atransient ischemic attack Stroke 2012431446ndash1447

20 Amarenco P Not all patients should be admitted to the hospital for observation after atransient ischemic attack Stroke 2012431448ndash1449

21 Douw K Nielsen CP Pedersen CR Centralising acute stroke care and moving care tothe community in a Danish health region challenges in implementing a stroke carereform Health Policy 20151191005ndash1010

22 Hastrup S Johnsen SP Terkelsen T et al Effects of centralizing acute stroke servicesa prospective cohort study Neurology 201891e236ndashe248

23 Johnston SC Rothwell PM Nguyen-Huynh MN et al Validation and refinement ofscores to predict very early stroke risk after transient ischaemic attack Lancet 2007369283ndash292

24 Giles MF Albers GW Amarenco P et al Addition of brain infarction to the ABCD2Score (ABCD2I) a collaborative analysis of unpublished data on 4574 patientsStroke 2010411907ndash1913

25 Giles MF Albers GW Amarenco P et al Early stroke risk and ABCD2 score per-formance in tissue- vs time-defined TIA a multicenter study Neurology 2011771222ndash1228

26 Merwick A Albers GW Amarenco P et al Addition of brain and carotid imaging tothe ABCD(2) score to identify patients at early risk of stroke after transient ischaemicattack a multicentre observational study Lancet Neurol 201091060ndash1069

27 Eliasziw M Kennedy J Hill MD Buchan AM Barnett HJ Early risk of stroke after atransient ischemic attack in patients with internal carotid artery disease Cmaj 20041701105ndash1109

28 Brott T Adams HP Jr Olinger CP et al Measurements of acute cerebral infarction aclinical examination scale Stroke 198920864ndash870

29 Mainz J Krog BR Bjornshave B Bartels P Nationwide continuous quality im-provement using clinical indicators the Danish National Indicator Project Int J QualHealth Care 200416(suppl 1)i45ndash50

30 Johnsen SP Ingeman A Hundborg HH Schaarup SZ Gyllenborg J The Danishstroke registry Clin Epidemiol 20168697ndash702

31 Thorvaldsen P Davidsen M Bronnum-Hansen H Schroll M Stable stroke occur-rence despite incidence reduction in an aging population stroke trends in the Danishmonitoring trends and determinants in cardiovascular disease (MONICA) pop-ulation Stroke 1999302529ndash2534

32 Wildenschild C Mehnert F Thomsen RW et al Registration of acute stroke validityin the Danish stroke registry and the Danish national registry of patients Clin Epi-demiol 2013627ndash36

33 Schmidt M Schmidt SA Sandegaard JL Ehrenstein V Pedersen L Sorensen HT TheDanish National Patient Registry a review of content data quality and researchpotential Clin Epidemiol 20157449ndash490

34 Pedersen CB Gotzsche H Moller JO Mortensen PB The Danish Civil RegistrationSystem a cohort of eight million persons Danish Med Bull 200653441ndash449

35 Katzan IL Spertus J Bettger JP et al Risk adjustment of ischemic stroke outcomesfor comparing hospital performance a statement for healthcare professionals from

Appendix Authors

Name Location Contribution

Sidsel HastrupMD PhD

AarhusUniversityHospitalDenmark

Designed and conceptualizedstudy obtained the officialapprovals data managementand statistical analysisinterpreted the data drafted themanuscript

Soren P JohnsenMD PhD

AalborgUniversityDenmark

Designed and conceptualizedstudy obtained the officialapprovals data managementand statistical analysisinterpreted the data revised themanuscript for intellectualcontents

Martin JensenMSc

AalborgUniversityDenmark

Datamanagement and statisticalanalysis interpreted the datarevised the manuscript forintellectual contents

Paul von Weitzel-MudersbachMD PhD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Claus ZSimonsen MDPhD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Niels Hjort MDPhD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Anette T MoslashllerMD PhD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Thomas HarboMD PhD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Marika SPoulsen MD

AarhusUniversityHospitalDenmark

Major role in the acquisition ofdata interpreted the datarevised the manuscript forintellectual contents

Helle K IversenMD DMSci

University ofCopenhagenDenmark

Designed and conceptualizedstudy interpreted the datarevised the manuscript forintellectual contents

Dorte DamgaardMD PhD

AarhusUniversityHospitalDenmark

Designed and conceptualizedstudy major role in theacquisition of data interpretedthe data revised the manuscriptfor intellectual contents

GretheAndersen MDDMSci

AarhusUniversityHospitalDenmark

Designed and conceptualizedstudy interpreted the datarevised the manuscript forintellectual contents guarantor

e1108 Neurology | Volume 96 Number 8 | February 23 2021 NeurologyorgN

the American Heart AssociationAmerican Stroke Association Stroke 201445918ndash944

36 ZhongW GengNWang P Li Z Cao L Prevalence causes and risk factors of hospitalreadmissions after acute stroke and transient ischemic attack a systematic review andmeta-analysis Neurol Sci 2016371195ndash1202

37 Oliver D Readmission rates reflect how well whole health and social care systemsfunction BMJ 2014348g1150

38 Bray BD Smith CJ Cloud GC et al The association between delays in screening forand assessing dysphagia after acute stroke and the risk of stroke-associated pneu-monia J Neurol Neurosurg Psychiatry 20178825ndash30

39 Magill SS Edwards JR Bamberg W et al Multistate point-prevalence survey of healthcare-associated infections N Engl J Med 20143701198ndash1208

40 Kiyohara T KamouchiM Kumai Y et al ABCD3 and ABCD3-I scores are superior toABCD2 score in the prediction of short- and long-term risks of stroke after transientischemic attack Stroke 201445418ndash425

41 Lovett JK Dennis MS Sandercock PA Bamford J Warlow CP Rothwell PM Veryearly risk of stroke after a first transient ischemic attack Stroke 200334e138ndash140

42 Johnston SC Short-term prognosis after a TIA a simple score predicts risk CleveClin J Med 200774729ndash736

43 Huang YC Hu CJ Lee TH et al The impact factors on the cost and length of stayamong acute ischemic stroke J Stroke Cerebrovasc Dis 201322e152ndash158

44 Sanders LM Cadilhac DA Srikanth VK Chong CP Phan TG Is nonadmission-basedcare for TIA patients cost-effective a microcosting study Neurol Clin Pract 2015558ndash66

45 Arefian H Heublein S Scherag A et al Hospital-related cost of sepsis a systematicreview J Infect 201774107ndash117

46 Perry C Papachristou I Ramsay AIG et al Patient experience of centralized acutestroke care pathways Health Expect 201821909ndash918

47 Sadighi A Stanciu A Banciu M et al Rate and associated factors of transient ischemicattack misdiagnosis eNeurologicalSci 201915100193

48 Vert C Parra-Farinas C Rovira A MR imaging in hyperacute ischemic stroke Eur JRadiol 201796125ndash132

49 Henriksen DP Rasmussen L Hansen MR Hallas J Pottegard A Comparison of thefive Danish regions regarding demographic characteristics healthcare utilization andmedication use a descriptive cross-sectional study PLoS One 201510e0140197

50 Craig P Cooper C Gunnell D et al Using natural experiments to evaluate populationhealth interventions new Medical Research Council guidance J Epidemiol Com-munity Health 2012661182ndash1186

NeurologyorgN Neurology | Volume 96 Number 8 | February 23 2021 e1109

DOI 101212WNL0000000000011453202196e1096-e1109 Published Online before print January 20 2021Neurology

Sidsel Hastrup Soren P Johnsen Martin Jensen et al Study

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke A Cohort

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