Optimising transient ischaemic attack (TIA) pathways to reduce ethnicity-based inequalities

Aim

To reduce ethnicity-based inequities in access to and delivery of TIA pathways to improve stroke outcomes for people from ethnic minority groups. Research Questions (RQ) 1 Does referral to or attendance at TIA clinic vary by ethnic group? 2 Do outcomes for patients with confirmed TIA following clinic attendance vary by ethnic group?

3 Are TIA pathways structured to meet the needs of people from ethnic minority groups? 4 How are TIA pathways experienced by people from ethnic minority groups?

5 What solutions can be applied to optimise TIA symptom awareness, presentation, and delivery of the TIA pathway for people from ethnic minority groups? Methods We plan 3 workpackages (WP): WP1 Investigation of ethnicity-based inequity in access to and delivery of TIA pathways (RQ1&2):

We will use linked primary and secondary care data in the Clinical Practice Research Datalink (CPRD) to investigate ethnicity based intersectional inequalities in referral to/attendance at TIA clinic, confirmed TIA occurrence, and stroke outcome at one year. Inclusion criteria: Age >=16 with first suspected or confirmed TIA recorded in electronic health records (EHR).

Analysis: Poisson regression with TIA clinic referral/attendance as service-level outcomes, number of patients with suspected TIA as offset and intersectional characteristics as random effects using a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) model. Analyses will be repeated with stroke following confirmed TIA as our main clinical outcome.

WP2 Investigating delivery of TIA pathways:

Case study design in three purposively sampled TIA systems based on demographics of the population they serve, informed by WP1. We will use process tracing of TIA pathway delivery. Iterative qualitative work using interviews and observations will generate and test theories that explain the ethnicity-based inequalities identified in WP1 (referral to, attendance at and outcome following TIA clinic).

WP3a Making sense of WP1 & WP2 feedback workshops for WP2 participants:

Feedback of WP1&2 findings to stakeholders, and prioritisation of areas for co-production work in interactive, multimedia workshops at each case study site for each of patients/carers and staff members. WP3b Generating culturally appropriate solutions:

Co-production of culturally appropriate materials for the public, patients, healthcare staff and guidance detailing essential elements of a more equitable TIA pathway for commissioners and providers to improve access, delivery and experience of TIA pathways for people from ethnic minority groups. PPI

This proposal has been developed in partnership with members of ethnically diverse local community groups, including stroke survivors. We have integrated PPI throughout the planned work, building on existing relationships to co-produce relevant and informed outputs. Timelines Prefunding work Month –7 to 2: Ethical approvals (WP1), acquisition of CPRD data and cleaning

WP1 Month 2–12: quantitative analysis and write up WP2 Month 5-14: Case study site identification and documentary analysis Month 7-21: Recruitment, interviews, observations Month 15-24: Analysis WP3 Month 23-28: Feedback of WP1&2 workshops, identifying focus for co-production work Month 28-38: Co-production workshops, development of outputs, reporting

Impact

We anticipate direct impact on health literacy in target groups, and on policy and practice to deliver culturally competent TIA pathways.