Award Title: SUPPORT TIA: Structured follow-Up Pathway to imProve management Of Residual impairmenTs and patients’ quality of life after Transient Ischaemic Attack and minor stroke: Intervention refinement and feasibility study.
Funder: Department of Health and Social Care

Abstract: Background The prevalence of transient ischaemic attack (TIA) and minor stroke in the UK is high; 510,000 and 300,000, respectively. Current long-term management of these conditions focuses on stroke prevention. However, my PhD research found that many TIA/minor stroke patients experience ongoing impairments, for which there are no guidelines or structured pathway of follow-up support. Residual impairments post-TIA/minor stroke could potentially reduce people's quality of life (QoL) and cause economic burden through reduced productivity at work and unplanned health/social care costs.Pilot work identified a demand from TIA/minor stroke patients and stakeholders for a structured pathway of support post-TIA/minor stroke. A preliminary intervention pathway has been informed by the pilot work and comprises: a follow-up appointment to screen for post-TIA/minor stroke impairments and refer patients to appropriate local support services (facilitated by a directory of services). However, further research is required to refine and test the feasibility this intervention pathway. Pilot work is currently underway to identify potential screening tools and time points for screening. The proposed research will identify the setting for the intervention pathway; develop the directory of support services; refine delivery of the intervention pathway; and test the feasibility and acceptability.Aims To (i) refine and (ii) test the feasibility and acceptability of an intervention pathway to improve management of residual impairments and QoL post-TIA/minor stroke.Plan of investigationWP-1: Qualitative interviews One-to-one, semi-structured qualitative interviews will help to understand the context of potential settings to follow-up and screen patients after TIA/minor stroke. Around 10-15 TIA/minor stroke patients will be identified from general practice patient lists and recruited by postal invitations. Around 30-35 healthcare providers will be recruited from TIA clinics, general practices and community/voluntary care.WP-2: Refine the content and delivery of the intervention pathway a) Healthcare professionals and TIA/minor stroke patients will be surveyed to identify local support services relevant for TIA/minor stroke in the West Midlands. Subsequently, an online directory of relevant support services in the West Midlands will be developed. b) The screening tools, time point for screening and setting for the follow-up appointment will be selected using data from the interviews (WP-1), the survey (WP-2a) and consultation with patients and stakeholders. c) A stakeholder engagement event will be held to refine the delivery of the intervention pathway. Behaviour change theories will also be used to inform the delivery and address the barriers to implementation of the pathway identified from the interviews (WP-1) and the survey (WP-2a).WP-3: Feasibility study A study will be conducted to assess the feasibility and acceptability of the intervention pathway. 60 TIA/minor stroke participants will be recruited from TIA clinics in the West Midlands and randomised 1:1 to the intervention pathway or control groups. Participants will be followed-up at three months. Quantitative and qualitative data will be collected to provide information on feasibility and acceptability outcomes.WP-5: Dissemination and grant writing Dissemination will encompass academic and non-academic routes and target key stakeholders and maximise impact. A protocol will be developed for a definitive randomised controlled trial (RCT) and a grant application produced to secure funding for this future research.Potential benefit to patients/the NHS There is potential for immediate benefit to patients/the NHS though dissemination of the online directory of support services. The intervention pathway has further potential to improve healthcare and QoL for TIA/minor stroke patients, which may impact on other important outcome such as return to work/social activities and management of stroke risk factors. There is a direct trajectory to patient/NHS benefit through a future definitive RCT. The proposed research will address research priorities of TIA/minor stroke patients and stakeholders.

Lay Abstract: What is the aim of the research? To design a care pathway that will help manage long-term problems after mini-stroke. The research will also test if the care pathway works practically to help decide if a larger study can be done.What is the problem and why is this important? Mini-strokes are similar to full strokes, but symptoms last less than 24 hours. Many people (up to 70%) have long-term problems after a mini-stroke, such as anxiety; depression; problems with brain functioning (like memory loss); and fatigue (feeling tired). However, the current healthcare pathway only focuses on preventing another stroke and care for other long-term problems is not routinely given. Without proper treatment, people with long-term problems after a mini-stroke could have worse quality of life and may find it difficult to return to work and their social activities.How will you address the problem? I have designed a new care pathway where people who have a mini-stroke will get a new follow-up appointment. At this appointment, a questionnaire will be used to identify which people have long-term problems and these people will be referred to local support services. More research is needed to help decide where the new follow-up appointment should be; to develop a database of local support services; and to design the details of how the new care pathway will be delivered. I will also test if the new care pathway works practically.There will be four stages to the project:Stage-1: I will interview people who have had a mini-stroke and people who deliver healthcare in hospitals, GP practices and the community. I will ask people about their experiences of the current care available and their opinions on the new care pathway.Stage-2: I will design the details of the new care pathway and how it will be delivered practically. Part a) I will send a survey to people who have had a mini-stroke, doctors, nurses and volunteers to find out what services are available in the West Midlands to support people with anxiety, depression, fatigue and brain functioning. This information will be put on a website so that doctors and nurses can easily search for local services. Part b) I will use the information from the interviews in stage one to decide where the follow-up appointment for the new care pathway should be, e.g. should it be in a hospital or in the community. Part c) I will consider practical issues to help design how the care pathway will be delivered. I will get advice from people who the care pathway is relevant to, including people who will deliver the pathway, people who have had a mini-stroke, stroke doctors, GPs and stroke charities.Stage-3: I will test the new care pathway to see if it works practically. 60 people who have had a mini-stroke will be involved: 30 will get the new care pathway and 30 will get normal care.Stage-4: I will share the findings from stages 1-3 with the general public and people who may want to use the new care pathway in the future, including patients, doctors and nurses, academics and politicians. I will also design a bigger study to test if the care pathway improves people's quality of life and management of long-term problems after mini-stroke.How have you involved patients and the public in your research? To help design the research project, I put together a group of people who have had a mini-stroke and their family members. This group has given advice on what they would want from a new care pathway. They also advised on the methods for the research, including how to recruit mini-stroke patients and if any parts of the research might cause upset or burden to participants. Members of this group (9 people) have agreed to continue to give advice during the research project.How will you share the findings of your research? I will share the findings of my researchers with the following people: Researchers Mini-stroke patients and the general public Healthcare staff: stroke doctors and nurses, GPs, community doctors and nurses, and volunteers. People who make decisions about health care services: politicians, policy makers and commissioners. A meeting will be held at the end of the study where all these groups of people will be invited to discuss the results and the next stages of research. The findings of the research will also be presented at research conferences; published in academic journals; and shared on social media and through summary leaflets.

Research Activity Codes: 7.1 INDIVIDUAL CARE NEEDS
Health Categories: STROKE