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Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community
  1. J Wright8,8,
  2. S Harrison1,
  3. M McGeorge2,8,
  4. C Patterson3,
  5. I Russell4,
  6. D Russell4,
  7. N Small5,
  8. M Taylor6,
  9. M Walsh7,
  10. E Warren8,
  11. J Young9
  1. 1Department of Applied Social Science, University of Manchester, Manchester, UK
  2. 2Department of Clinical Epidemiology, Bradford Royal Infirmary, Bradford, UK
  3. 3Consultant in Care of the Elderly, Bradford Teaching Hospital Trust, Bradford, UK
  4. 4Institute of Medical and Social Care Research, University of Wales, Bangor, UK
  5. 5School of Health Studies, Bradford University, Bradford, UK
  6. 6Bradford City Primary Care Trust, Bradford, UK
  7. 7Bradford South and West Primary Care Trust, Bradford, UK
  8. 8Clinical Quality and Research Unit, Bradford Teaching Hospitals Trust, Bradford, UK
  9. 9Bradford Teaching Hospitals Trust and University of Leeds, UK
  1. Correspondence to:
 Dr J Wright
 Consultant in Clinical Epidemiology and Public Health, Bradford Teaching Hospital Trust, Bradford Royal Infirmary, Bradford BD9 6RJ, UK; john.wright{at}


Problem: Rapid referral and management of patients with transient ischaemic attacks is a key component in the national strategy for stroke prevention. However, patients with transient ischaemic attacks are poorly identified and undertreated.

Design and setting: Before and after evaluation of quality improvement programme with controlled comparison in three primary care trusts reflecting diverse populations and organisational structures in an urban district in the North of England.

Key measures for improvement: The proportion of patients receiving antiplatelet drugs and safe driving advice on referral to a speciality clinic, and the numbers of referrals, adjusted for age, to the specialist clinic before and after the improvement programme.

Strategies for change: Interviews with patient and professionals to identify gaps and barriers to good practice; development of evidence based guidelines for the management of patients with transient ischaemic attacks; interactive multidisciplinary workshops for each primary care trust with feedback of individual audit results of referral practice; outreach visits to teams who were unable to attend the workshops; referral templates and desktop summaries to provide reminders of the guidelines to clinicians; incorporation of standards into professional contracts.

Effects of change: A significant improvement occurred in identification and referral of patients with transient ischaemic attacks to specialist clinics, with a 41% increase in referrals from trained practices compared with control practices. There were also significant improvements in the early treatment and safety advice provided to patients before referral.

Lessons learnt: A strategic approach to effective quality improvement across a diverse health community is feasible and achievable. Careful planning with patient and professional involvement to develop a tailored and multifaceted quality improvement programme to implement evidence based practice can work in very different primary care settings. Key components of the effectiveness of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication, and use of established networks and opinion leaders.

  • quality improvement report
  • stroke prevention
  • clinical guidelines
  • transient ischaemic attacks
  • implementation of change

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  • JW and JY had the original idea for the project. JW, SH, CP, IR, NS and JY designed the project and obtained funding. All authors had an active role in the development of the guidelines and their subsequent implementation. MM coordinated the project. DR undertook the analysis. JW wrote the paper in collaboration with the other authors and is the guarantor.

  • Funding: Department of Health.

  • Competing interests: none.

  • The project was reviewed and approved by the Bradford Local Ethics Committee

    Further details on the guideline and supporting materials can be found at + Documents.