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Theme 7: Optimisation of the management of stroke and transient ischaemic attack

A transient ischaemic attack (TIA) or small stroke is a sentinel event for a lethal or incapacitating stroke. Recent evidence shows that the risk of a second cataclysmic event can be materially reduced by rapid assessment and treatment. Research also shows that such preventative action is seldom evoked. Similarly, effective utilisation of thrombolysis for acute stroke is critically dependent on early intervention and currently benefits less than one per cent of stroke sufferers, due in significant part to delays in presentation to specialised units.

Our Approach

This project, at the interface of research and implementation, will monitor the quality of care, evaluate barriers to best practice, and provide interim results to service managers and practitioners on an iterative basis in order to promote preventative actions. The hypothesis is that such a programme of investigation will result in positive change. If so, there will be fewer strokes and we will model the contingent societal benefits mathematically.

Our projects

Optimisation of the Management of Stroke and Transient Ischaemic Attack

Our programme of work comprised a series of epidemiological, modelling and service improvement studies made up of:

  • Systematic data collection from both primary and secondary care
  • Comparison of current care to gold standard care and identification of barriers to such care
  • Presentation of these results to inform stakeholders both at the population and individual patient levels
  • Iterative development of stroke and transient ischaemic attack (TIA) services using cycles of data collection and feedback
  • evaluation of this initiative in terms of cost-effectiveness combined with qualitative analysis of patient and healthcare professional interviews and finally to develop the local infrastructure to allow further research on stroke and TIA.

Initial development of this theme took place in South Birmingham Primary Care Trust, Birmingham East and North Primary Care Trust, two local specialist services, namely University Hospitals Birmingham NHS Foundation Trust and Heart of England NHS Foundation Trust, and the West Midlands Ambulance Service.

We aimed to optimise the acute management of people with TIA and stroke in Birmingham through identifying and breaking down current barriers to timely and effective treatment. Our aims were as follows:

  1. To collect epidemiological data including clinical features, symptom and management timing, and resource use data from people with TIA and stroke from local secondary care outpatient, inpatient and A&E services; West Midlands Ambulance Service; local general practice clinical systems; consenting individual patients.
  2. To compare this data with optimum care using both best practice in terms of published data, including the National Sentinel Audit for stroke along with the results from our previously developed discrete event simulation model for TIA management and a model currently in development for acute stroke care. This comparison was used to ascertain the reasons why actual care deviates from recommended practice, resulting in the identification of key barriers to optimum care.
  3. To use the results from aims 1 and 2 (above) to inform local commissioners of care, GPs, specialists and patients regarding gaps in or barriers to optimal care both for the health economy as a whole (for example, in terms of service organisation) and at an individual level (for example, where secondary preventative care could be improved for individual patients). Where appropriate, we communicated with regional or national services such as NHS Direct to further intervene in the community and primary care using the FAST test to hasten the specialist review for people with signs and symptoms of TIA or stroke.
  4. To perform an iterative service improvement programme using cycles of one to three.
  5. To assess the impact of this initiative on care for people with TIA and stroke by a) using the models to predict gains in terms of morbidity, mortality and the effects on costs and b) to perform the qualitative research with local commissioners of care, GPs, specialists and patients.
  6. To produce a cohort of people with TIA and stroke which could be utilised for further research projects.

Strokes & Ladders educational game

We developed a fun educational tool to help both children and adults recognise the signs and symptoms of stroke and start conversations around contacting the emergency services. If you follow the link you can print a copy off for your use.

Communication about Sexual Wellbeing Post Stroke

This sub-study aimed to understand health care professionals and patients experiences and perspectives of information giving on sexual wellbeing post-stroke. In-depth interviews were conducted with patients and health care professionals across the patient pathway to establish this.

This work was further developed to examine health care professional – patient discussion of sexual wellbeing in adults more widely and a systematic review protocol was designed.

Observation of Blood Pressure Control Post Stroke

In addition to studies relating to the management of patients with existing stroke and TIA, we also undertook work aimed at preventing cardiovascular disease. These included data analysis projects and systematic literature reviews designed to better understand and improve the way blood pressure is measured in clinical practice. We also conducted studies into how well patients are prescribed medication to prevent cardiovascular disease. It is hoped that these projects will lead to future work trialing new prevention strategies to reduce the number of patients suffering from stroke and TIA in the future.


This research was about understanding how we can get individuals who have had a stroke to hospital quickly, specifically investigating the role of Primary Care reception staff. We know that patients who contact their General Practitioner (GP) are delayed and do not benefit from the most effective treatment available. Understanding why this is will help identify opportunities to improve stroke care.
We aimed to understand how Primary Care reception staff acted during telephone conversations with individuals experiencing stroke symptoms or their carers, identifying any areas for improvement. Developing methods to minimise delay will potentially improve patient quality of life.

We collected data through:

  1. A short questionnaire to receptionists
  2. Assessment of GP out-of-hours answer phone messages
  3. Interviews and group discussions with staff

This study did not involve stroke survivors directly. We used ‘actors’ to role play as patients or relatives of patients experiencing stroke symptoms who contact their GP. The response from the GP practices was investigated.

As a result of this work we are developing a stroke recognition training programme for GP receptionists and practice managers.

Author(s) Title Journal Publication date
Mellor, R; Greenfield, S; Dowswell, G; Sheppard, J; Quinn, T; McManus, R Health Care Professionals' Views on Discussing Sexual Wellbeing with Patients who have had a Stroke: A Qualitative Study PLoS One
8(10): e78802. doi:10.1371/journal.pone.0078802
29 October 2013
Sheppard, JP; Mellor, RM, Greenfield, S; Mant, J; Quinn, T; Sandler, D; Sims, D; Singh, S; Ward, M; McManus RJ The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study Emergency Medicine Journal
doi: 10.1136/emermed-2013-203026.
7 October 2013
Edwards, D; Fletcher, K; Deller, R; McManus, R; Lasserson, D; Giles, M; Sims, D; Norrie, J; McGuire, G; Cohn, S; Whittle, F; Hobbs, V; Weir, C; Mant, J RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial Trials
2013 Jul 2;14(1):194.
2 July 2013
Hodgkinson, JA; Sheppard, JP; Heneghan, C; Martin, U; Mant; J; McManus, RJ Accuracy of ambulatory blood pressure monitors: a systematic review of validation studies Journal of Hypertension
doi: 10.1097/HJH.0b013e32835b8d8b
1 February 2013
Bietzk, E; Davies, R; Floyd, A; indsay, A; Greenstone, H; Symonds, A & Greenfield, S FAST enough? The UK general public’s understanding of stroke Clinical Medicine
2012, 12;5:410-415
1 October 2012
Theme lead

Professor Richard McManus
Professor of Primary Care Cardiovascular Research
University of Oxford

  • Heart of England NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust
  • West Midlands Ambulance Service NHS Foundation Trust
  • Sandwell and West Birmingham Hospitals NHS Trust
  • Former Birmingham East and North Primary Care Trust Former South Birmingham Primary Care Trust Birmingham
  • Sandwell and Solihull Cardiac and Stroke Network
  • University of Birmingham