Testing a rapid outpatient management strategy on PTSD, cardiovascular and rehospitalization risk in TIA and minor stroke survivors evaluated in the Emergency Department

测试针对 PTSD、TIA 心血管和再住院风险以及急诊科评估的轻微中风幸存者的快速门诊管理策略

• 批准号: 10208939
• 负责人: Bernard P. Chang
• 金额: $ 75.19万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-01 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10208939
• 关键词: Academic Medical Centers; Accelerometer; Accident and Emergency department; Acute; Admission activity; Affect; Autonomic nervous system; Blood Vessels; Calculi; Cardiovascular Diseases; Cardiovascular system; Caring; Clinic; Clinical; Clinical Practice Variations; Cohort Studies; Development; Devices; Diagnostic Imaging; Disease; Disease Outcome; Electrocardiogram; Eligibility Determination; Emergency Care; Emergency Department evaluation; Enrollment; Environment; Equipoise; Ethics; Evaluation; Event; Exposure to; Funding; Guidelines; Heart Rate; Home; Hospitalization; Hour; Infrastructure; Inpatients; Intuition; Ischemia; Knowledge; Link; Measures; Medical; Minor; Monitor; National Heart, Lung, and Blood Institute; Natural experiment; Neurologic Dysfunctions; Neurology; Outcome; Outcome Study; Outpatients; Participant; Pathway interactions; Patient-Focused Outcomes; Patients; Physiological; Post-Traumatic Stress Disorders; Randomized; Recurrence; Relative Risks; Research; Research Design; Risk; Safety; Schedule; Stress; Stroke; Survivors; Symptoms; Testing; Time; Transient Ischemic Attack; United States National Institutes of Health; Variant; acute care; acute coronary syndrome; acute stress; adjudicate; cardiovascular disorder risk; clinical decision-making; cost; design; disorder risk; follow-up; heart rate variability; hospital readmission; improved; indexing; inpatient service; mortality; mortality risk; patient-clinician communication; post stroke; primary outcome; psychologic; secondary outcome; stroke patient; stroke risk; stroke survivor; stroke symptom

Recent research suggests that exposure to stressful aspects of emergency department (ED) and inpatient care may increase risk for subsequent posttraumatic stress disorder (PTSD) and recurrent cardiovascular events in patients who present to the ED with transient ischemic attacks and minor strokes (TIAMS). There are currently no established clinical guidelines for emergency department (ED) management of TIAMS after the initial evaluation and safety determination. This study will compare psychological and long-term cardiovascular outcomes associated with the two most widely employed strategies for managing TIAMS patients in US EDs. We will use an observational design to compare TIAMS-induced PTSD symptoms, 30-day rehospitalization, and 1-year cardiovascular disease (CVD)/mortality outcomes in TIAMS patients managed according to (1) ED evaluation followed by inpatient admission strategy, versus (2) rapid ED evaluation and discharge with a scheduled next-day outpatient neurology follow-up. Further, we will assess autonomic nervous system (ANS) reactivity to the 2 strategies using ambulatory ECG. This study design is possible because of a newly established Rapid Access Vascular Evaluation- Neurology (RAVEN) TIAMS care pathway, which will be available for 2 weeks per month (on alternating weeks) at Columbia University Medical Center. We hypothesize that patients treated during RAVEN weeks will have lower PTSD symptoms, reduced 30d rehospitalization, and lower 1- year CVD/mortality risk relative to those treated during the inpatient admission strategy weeks. We will explore whether ANS markers of stress (ambulatory heart rate (HR) and heart rate variability (HRV) in the 3 days after ED presentation) explain any group differences in study outcomes. Nearly 1 in 5 TIA/MS survivors screen positive for PTSD in the month after the event, and research in other CVD patients suggests that PTSD may increase risk for recurrent CVD events. To date, research linking ED/inpatient exposure with subsequent PTSD has been unable to disentangle the stress that results from the medical event itself from stress resulting from the hectic ED/inpatient stay. If our hypothesis is correct -- that rapid ED discharge and outpatient follow-up reduces PTSD symptoms and improves clinical outcomes in TIAMS survivors-- the results of our study will impact clinical guidelines immediately. Furthermore, the study will have broader implications for the clinical calculus of ED care versus outpatient follow-up for many other diseases, such as acute coronary syndrome, traditionally managed with prolonged ED observation and inpatient care.

最近的研究表明，暴露于急诊科（艾德）的压力方面， 住院治疗可能会增加后续创伤后应激障碍（PTSD）和复发的风险。 在因短暂性脑缺血发作和轻微脑缺血发作就诊于艾德的患者中， 中风（TIAMS）。目前没有既定的急诊科临床指南 (ED)在初步评估和安全性确定后，管理TIAMS。本研究将 比较心理和长期心血管结果与两个最广泛的 在US ED中采用管理TIAMS患者的策略。 我们将使用观察设计比较TIAMS诱导的PTSD症状，30天 TIAMS患者的再住院和1年心血管疾病（CVD）/死亡结局 根据（1）艾德评估后的住院策略进行管理，与（2）快速 艾德评价和出院，并安排第二天门诊神经病学随访。此外，本发明还 我们将使用动态心电图评估自主神经系统（ANS）对这两种策略的反应性。 本研究设计是可能的，因为新建立的快速血管通路评价- 神经科（RAVEN）TIAMS护理途径，每月提供2周（在 每隔一周）在哥伦比亚大学医学中心。我们假设接受治疗的患者 在RAVEN周期间，创伤后应激障碍症状较轻，30天再住院减少，1- 年CVD/死亡风险相对于那些在住院治疗策略周治疗。我们 将探讨压力的ANS标志物（动态心率（HR）和心率变异性）是否 (HRV)在艾德就诊后3天内）解释研究结果的任何组间差异。 近五分之一的TIA/MS幸存者在事件发生后的一个月内对PTSD筛查呈阳性， 在其他CVD患者中，PTSD可能会增加CVD事件复发的风险。到目前为止， 将艾德/住院患者暴露与随后的PTSD联系起来的研究无法解开这一谜团。 由医疗事件本身引起的压力，由忙碌的艾德/住院病人引起的压力 留下吧如果我们的假设是正确的--快速的艾德出院和门诊随访减少了创伤后应激障碍 症状和改善TIAMS幸存者的临床结局-我们的研究结果将影响 临床指南立即此外，这项研究将对 艾德护理的临床结石与许多其他疾病的门诊随访相比， 冠状动脉综合征，传统上通过长期艾德观察和住院治疗进行管理。