Rural versus metropolitan comparison of processes of care in the community-based management of TIA and minor stroke in Australia (an analysis from the INSIST study).

OBJECTIVES: To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. DESIGN: Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST). SETTING: Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC). PARTICIPANTS: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. MAIN OUTCOME MEASURES: Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes. RESULTS: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. CONCLUSIONS: Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

One-Year Risk of Stroke After Transient Ischemic Attack or Minor Stroke in Hunter New England, Australia (INSIST Study).

Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5-8%. However, evidence for the outcomes of TIAMS in community care settings is limited. Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the Hunter-Manning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-days, 90-days, and 1-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 h post-index event. Results: Of 613 participants (mean age; 70 ± 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and 1-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3, 0.3, and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularizations (1.5%), eleven carotid revascularizations (3.9%), and three deaths (1.1%), compared to 1.6, 0.6, 1.0, 0.3, and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 h post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 h [IQR 1.8-89.9]. Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence.

The Characteristics of Patients With Possible Transient Ischemic Attack and Minor Stroke in the Hunter and Manning Valley Regions, Australia (the INSIST Study).

Background: Transient ischemic attack (TIA) and minor stroke (TIAMS) are risk factors for stroke recurrence. Some TIAMS may be preventable by appropriate primary prevention. We aimed to recruit "possible-TIAMS" patients in the INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study. Methods: A prospective inception cohort study performed across 16 Hunter-Manning region, Australia, general practices in the catchment of one secondary-care acute neurovascular clinic. Possible-TIAMS patients were recruited from August 2012 to August 2016. We describe the baseline demographics, risk factors and pre-event medications of participating patients. Results: There were 613 participants (mean age; 69 ± 12 years, 335 women), and 604 (99%) were Caucasian. Hypertension was the most common risk factor (69%) followed by hyperlipidemia (52%), diabetes mellitus (17%), atrial fibrillation (AF) (17%), prior TIA (13%) or stroke (10%). Eighty-nine (36%) of the 249 participants taking antiplatelet therapy had no known history of cardiovascular morbidity. Of 102 participants with known AF, 91 (89%) had a CHA2DS2-VASc score ≥ 2 but only 47 (46%) were taking anticoagulation therapy. Among 304 participants taking an antiplatelet or anticoagulant agent, 30 (10%) had stopped taking these in the month prior to the index event. Conclusion: This study provides the first contemporary data on TIAMS or TIAMS-mimics in Australia. Community and health provider education is required to address the under-use of anticoagulation therapy in patients with known AF, possibly inappropriate use of antiplatelet therapy and possibly inappropriate discontinuation of antiplatelet or anticoagulation therapy.

Quality of referrals and guideline compliance for time to consultation at an acute neurovascular clinic.

BACKGROUND: The Age, Blood pressure, Clinical features, Duration of symptoms, Diabetes (ABCD2) score can be used to predict early recurrent stroke risk following Transient ischemic attack (TIA). Given that recurrent stroke risk can be as high as 20% in the first week, international guidelines recommend "high-risk" TIAs (ABCD2 >3) be seen by specialist services such as dedicated acute neurovascular clinics within 24 hours. The goal of this study was to examine the associations of both quality of referrals to a specialist acute clinic and of "guideline congruence" of time-to-clinic consultation after TIA/minor stroke. We hypothesized high-quality referrals containing key clinical elements would be associated with greater guideline congruence. METHODS: A retrospective analysis of referrals to an acute neurovascular clinic within a tertiary care hospital of consecutive patients with TIA/minor stroke. Quality of general practitioner and emergency department referrals was defined on the basis of information content enabling ABCD2-based risk stratification by the clinic triage service. Time-to-clinic consultation was used to define "guideline congruence." RESULTS: Referrals of 148 consecutive eligible patients were reviewed. Sixty-six percent of cases were subsequently neurologist-diagnosed as TIA or minor stroke. Seventy-nine percent were referred by general practitioners. Fifty-three percent of referrals were of high quality, but quality was not associated with guideline congruence. Of the high-risk patients, only 3.6% were seen at the clinic within 24 hours of index event and 31.3% within 24 hours of referral. CONCLUSIONS: Current guidelines are pathophysiologically logical and evidence based, but are difficult to implement. Improving quality of primary-secondary communication by improved referral quality is unlikely to improve guideline compliance. Alternative strategies are needed to reduce recurrent stroke risk after TIA/minor stroke.

Absolute cardiovascular risk and GP decision making in TIA and minor stroke.

BACKGROUND: Transient ischaemic attacks (TIA) and minor strokes (TIAMS) have the same pathophysiological mechanism as stroke and carry a high risk of recurrent ischaemic events. Diagnosis of TIAMS can be challenging and often occurs in general practice. Absolute cardiovascular risk (ACVR) is recommended as the basis for vascular risk management. Consideration of cardiovascular risk in TIAMS diagnosis has been recommended but its utility is not established. OBJECTIVES: Firstly, to document the ACVR of patients with incident TIAMS and with TIAMS-mimics. Secondly, to evaluate the utility of ACVR calculation in informing the initial diagnosis of TIAMS. METHODS: The International comparison of Systems of care and patient outcomes in minor Stroke and TIA (InSiST) study is an inception cohort study of patients of 17 Australian general practices presenting as possible TIAMS. An expert panel determines whether participants have had TIAMS or TIAMS-mimics. ACVR was calculated at baseline for each participating patient. In this cross-sectional baseline analysis, ACVR of TIAMS and TIAMS-mimics were compared univariately and, also, when adjusted for age and sex. The diagnostic utility of ACVR was evaluated via receiver operating characteristic (ROC) curves. RESULTS: Of 179 participants, 87 were adjudicated as TIAMS. The presence of motor and speech symptoms and body mass index were associated with a diagnosis of TIAMS. ACVR was associated with TIAMS diagnosis on univariate analysis, but not when age- and sex-adjusted. ACVR did not significantly improve area under ROC curves beyond that of age and sex. CONCLUSION: In patients presenting with transient or minor neurological symptoms, calculation of ACVR did not improve diagnostic accuracy for TIAMS beyond that of age and sex.

TV Corporativa: a experiência da Secretaria Municipal da Saúde na implantação do Canal Profissional da Rede São Paulo Saudável de Televisão

Este trabalho tem como objetivo estudar as estratégias adotadas pela Secretaria Municipal de Saúde na implantação da Rede São Paulo Saudável de Televisão Canal Profissional, tendo em vista os grandes desafios de se implantar métodos inovadores da gestão pública. A Secretaria Municipal de Saúde de São Paulo conta com 80 mil colaboradores, a Coordenação de Gestão de Pessoas tem como missão formar e capacitar seus profissionais constantemente, tendo como estratégia o Canal Profissional da Rede São Paulo Saudável de Televisão

TV Corporativa: a experiência da Secretaria Municipal da Saúde na implantação do Canal Profissional da Rede São Paulo Saudável de Televisão / Corporate TV: the experience of the municipal health department in the implementation of professional channel network Sao Paulo healthy TV

Este trabalho tem como objetivo estudar as estratégias adotadas pela Secretaria Municipal de Saúde na implantação da Rede São Paulo Saudável de Televisão Canal Profissional, tendo em vista os grandes desafios de se implantar métodos inovadores da gestão pública. A Secretaria Municipal de Saúde de São Paulo conta com 80 mil colaboradores, a Coordenação de Gestão de Pessoas tem como missão formar e capacitar seus profissionais constantemente, tendo como estratégia o Canal Profissional da Rede São Paulo Saudável de Televisão (AU)

A tecnologia audiovisual utilizada para informar e capacitar os trabalhadores da Secretaria Municipal da Saúde

A Secretaria Municipal da Saúde de São Paulo inaugurou em 2008 uma rede de transmissão e recepção de sinais de TV digital via satélite, a Rede São Paulo Saudável, contando com 02 (dois) estúdios de geração e 03 (três) canais de TV: Canal Cidadão, Canal Profissional e o Canal Interativo. A Rede São Paulo Saúdável é gerenciada pela Área Técnica de Tecnologia de Informação da SMS - ATTI, e a coordenação do Canal do Cidadão de responsabilidade do Núcleo de Programas Estratégicos - NUPES que transmite pela TV conteúdo educativo de promoção a saúde da população. Coube a Coordenação de Gestão de Pessoas, por meio da Escola Municipal da Saúde e seu Núcleo de Comunicação e TV a gestão do Canal Profissional e Canal Interativo, tem como objetivo principal, melhorar a capacitação dos profissionais por meio de Educação a Distância. Com o intuito de atender as necessidades e demandas apontadas pelos profissionais e áreas técnicas da SMS, iniciamos o processo de reestruturação na grade do Canal 2 - Canal Profissional da Rede São Paulo Saudável a partir de Maio de 2010. O presente trabalho visa apresentar o caminho percorrido na implantação do Canal Profissional e os primeiros resultados obtidos na reformulaçao da grade da programação no mês de Julho de 2010 a Julho de 2011.

A tecnologia audiovisual utilizada para informar e capacitar os trabalhadores da Secretaria Municipal da Saúde / The audiovisual technology used to inform and train workers of the Municipal Health Secretariat

A Secretaria Municipal da Saúde de São Paulo inaugurou em 2008 uma rede de transmissão e recepção de sinais de TV digital via satélite, a Rede São Paulo Saudável, contando com 02 (dois) estúdios de geração e 03 (três) canais de TV: Canal Cidadão, Canal Profissional e o Canal Interativo. A Rede São Paulo Saúdável é gerenciada pela Área Técnica de Tecnologia de Informação da SMS - ATTI, e a coordenação do Canal do Cidadão de responsabilidade do Núcleo de Programas Estratégicos - NUPES que transmite pela TV conteúdo educativo de promoção a saúde da população. Coube a Coordenação de Gestão de Pessoas, por meio da Escola Municipal da Saúde e seu Núcleo de Comunicação e TV a gestão do Canal Profissional e Canal Interativo, tem como objetivo principal, melhorar a capacitação dos profissionais por meio de Educação a Distância. Com o intuito de atender as necessidades e demandas apontadas pelos profissionais e áreas técnicas da SMS, iniciamos o processo de reestruturação na grade do Canal 2 - Canal Profissional da Rede São Paulo Saudável a partir de Maio de 2010. O presente trabalho visa apresentar o caminho percorrido na implantação do Canal Profissional e os primeiros resultados obtidos na reformulaçao da grade da programação no mês de Julho de 2010 a Julho de 2011.(AU)

A tecnologia audiovisual utilizada para informar e capacitar os trabalhadores da Secretaria Municipal da Saúde / The audiovisual technology used to inform and train workers of the Municipal Health Secretariat

A Secretaria Municipal da Saúde de São Paulo inaugurou em 2008 uma rede de transmissão e recepção de sinais de TV digital via satélite, a Rede São Paulo Saudável, contando com 02 (dois) estúdios de geração e 03 (três) canais de TV: Canal Cidadão, Canal Profissional e o Canal Interativo. A Rede São Paulo Saúdável é gerenciada pela Área Técnica de Tecnologia de Informação da SMS - ATTI, e a coordenação do Canal do Cidadão de responsabilidade do Núcleo de Programas Estratégicos - NUPES que transmite pela TV conteúdo educativo de promoção a saúde da população. Coube a Coordenação de Gestão de Pessoas, por meio da Escola Municipal da Saúde e seu Núcleo de Comunicação e TV a gestão do Canal Profissional e Canal Interativo, tem como objetivo principal, melhorar a capacitação dos profissionais por meio de Educação a Distância. Com o intuito de atender as necessidades e demandas apontadas pelos profissionais e áreas técnicas da SMS, iniciamos o processo de reestruturação na grade do Canal 2 - Canal Profissional da Rede São Paulo Saudável a partir de Maio de 2010. O presente trabalho visa apresentar o caminho percorrido na implantação do Canal Profissional e os primeiros resultados obtidos na reformulaçao da grade da programação no mês de Julho de 2010 a Julho de 2011.