The Transient Ischemic Attack (TIA) And Minor Stroke (TAMS) Unit Ambulatory Care Model Provides More Efficient Care with Clinical Outcomes Similar to Inpatient Care
Cardiovascular and Stroke Care
The Transient Ischemic Attack (TIA) And Minor Stroke (TAMS) Unit is a rapid-access, day-unit care model that is unique in Ontario and Canada. It was developed to provide care for high-risk patients with TIA or minor (non-disabling) stroke; avoiding hospital admission, which was the standard of care. In a two-year study, patients seen in the TAMS Unit had low one- and three-month rates of admission for new/recurrent stroke similar to a propensity-matched control cohort of TIA/minor stroke patients managed in hospital. Additionally, TAMS Unit patients had a lower rate of death within one year of index TIA/minor stroke compared to inpatient controls. The TAMS Unit care model has led healthcare system transformation by informing recommendations including through the Ontario Health Technology Advisory Committee (OHTAC) and the Quality-Based Procedures (QBP) Stroke Clinical Handbook.
Background: Patients with transient ischemic attack (TIA) require urgent evaluation and initiation of stroke prevention strategies given subsequent stroke risk but often there are challenges in accessing timely, comprehensive care. We developed an ambulatory day-unit, the TIA And Minor Stroke (TAMS) Unit, to address this care need.
Methods: Between Sept. 2011-Aug. 2013, we evaluated patients with suspected TIA or minor stroke in the TAMS Unit at Toronto Western Hospital. We compared processes of care and the outcomes of new/recurrent stroke and death in patients seen in the TAMS Unit compared to inpatient care. We used propensity matching to identify patient pairs and compared outcome rates between the matched study cohorts.
Results: In the study period, 359 TAMS Unit patients were seen: 63.1% with TIA/stroke and 36.9% non-TIA/stroke diagnoses. In 128 matched TIA and minor stroke pairs, within 30 days of index event, there was no difference in stroke risk. At 1 year, there were fewer strokes among TAMS Unit patients (rate 0.039) versus inpatients (rate 0.125, McNemar p-value=0.019), though not significant after correction for multiple comparisons, and there were fewer deaths in TAMS Unit patients. More TAMS Unit patients obtained neurovascular imaging (100% of TIA patients versus 95.6% of inpatients, Standardized Mean Difference, SMD, 0.3) and Holter monitoring (64.4% of TIA patients versus 42.2% of inpatients, SMD 0.45; and 84.3% of stroke patients versus 31.3% of inpatients, SMD 1.26).
Conclusion: Outcomes in the TAMS Unit were similar to inpatient care and access to investigations was better. Such day-units should be considered for development in all centres that provide stroke care/prevention services.