Stopping the strokes: general practitioner engagement with transient ischaemic attack

Problem

Stroke risk after transient ischaemic attack (TIA) is highest in the first few days, but can be greatly reduced with prompt commencement of commonly used medications. Current Australian guidelines recommend that all TIAs be managed urgently by secondary care specialists (mandatory for high-risk TIAs). However, the majority of TIAs present to general practice which creates a management dilemma when specialist care is not readily accessible as is commonly the case. There is no Australian evidence relating to this, neither for experienced general practitioners (GPs) nor GPs in training. Examining these groups could offer insight into behaviours that underpin quality practice, so we explored management of TIA presentations by experienced GPs and GP trainees.

Approach

A qualitative study of a maximum variation sample using semi-structured interviews of 8 GP supervisors and 14 GP registrars from two regional training providers was conducted. Interviews were informant-led as far as possible to allow for emergence of new themes, and discussed personal experiences as well as hypothetical scenarios. Summarising and paraphrasing were used to confirm the interviewer’s understanding of the participant’s meaning. The interviews were recorded and transcribed verbatim. Data collection and analysis were concurrent and iterative, employing constant comparison, inductive thematic analysis, and proceeded until thematic saturation was achieved. Participants had the opportunity to review and clarify their transcript. Co-coding was conducted and reflexivity was employed at all stages.

Findings

Diagnosis of TIA was seen as challenging and help-seeking was a common feature. There was little awareness of published management guidelines, and management choices relating to advice, medications, investigations and referral were heterogeneous. Access to secondary care specialists was seen as a particular problem for rural patients. Initial management of a particular TIA depended upon the GP’s level of engagement with the individual case. The level of engagement was predicated on the GP’s predisposition to managing TIA in general, the case’s clinical features, patient factors and health system factors. The GP’s level of engagement can vary from case-to-case and over time, which leads to variability in the management approach chosen. TIA management approaches formed a spectrum comprising “triage”, “guided collaboration (with secondary care)”, “consultative collaboration”, “independent management”, and “misdiagnosis”. Collaboration with secondary care specialists increased the GPs’ capability for diagnosing and managing future TIAs.

Consequences

Although a qualitative study cannot estimate compliance with guidelines it can suggest means for improvement. Increasing the capability of GPs to manage TIAs through collaboration, creates the possibility of more effective management while awaiting secondary care assessment, particularly with regard to reducing stroke incidence after high-risk TIA. It could also reduce heterogeneity of specific management choices made. Future Australian guidelines could consider systems approaches to assist primary care management of TIA and promote a collaborative approach.