Service factors causing delay in specialist assessment for transient ischaemic attack and minor stroke: a qualitative study of GP and patient perspectives

Objective: To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke. Design: Qualitative study using semi-structured interviews, analysis by constant comparison. Setting: Leicester, UK. Participants: Patients diagnosed with TIA or minor stroke at hospital admission or in a rapid access TIA clinic (n=42), general practitioners of participating patients if they had been involved in the patients’ care (n=18). Data: Accounts from patients and GPs of factors contributing to delay following action to seek help from a health care professional (HCP). Results: The following categories of delay were identified. Firstly, delay in assessment in general practice following contact with the service; this related to availability of same day appointments and the role of the receptionist in identifying urgent cases. Secondly, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out of hours services, walk in centres and the Emergency Department. Thirdly, delays in referral after a suspected diagnosis; these included variable use of the ABCD2 risk stratification score and referral templates in general practice, and referral back to the patients’ GP in cases where he/she was not the first HCP consulted. Conclusions: Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.