Abstract WMP27: Decreasing Emergency Department admission rate for TIA contrasts with rising cost of TIA evaluation from 2013-2021

Introduction: For the 240,000 patients presenting to the emergency department (ED) annually with transient ischemic attack (TIA), a resource-intensive multimodal evaluation and possible admission to the hospital may help prevent a subsequent stroke. Multiple strategies to approach the location and timing of these evaluations exist. Using a nationally representative data source, we evaluated variation and trends in ED practices for patients with suspected TIA. Methods: Retrospective cross-sectional study of ED visits using the 2013-2021 National Emergency Department Sample, a 20% sample of ED encounters in the United States maintained by the Healthcare Cost and Utilization Project (HCUP). TIA diagnosis was determined by first-listed ICD-9 or -10 code. Imaging utilization was determined in discharged ED patients by CPT code for TIA related modalities. Factors associated with discharge from the ED in a TIA encounter were evaluated with a multivariable logistic regression. Results: Percentage of ED TIA patients discharged from the ED increased from 47% (95%CI 46-49) to 68% (95% CI 66-69) between 2013 and 2021. Average cost per discharged TIA encounter increased from $1559 (95% CI 1482-1635) to $2753 (95% CI 2649-2857). Imaging utilization in discharged TIA patients increased markedly between 2013 and 2021. In 2013, 3.6% (95% CI 2.8-4.4) of discharged TIA patients received a CTA Head during their evaluation, while in 2021 this had increased to 44%(95% CI 42-46). Logistic regression analysis for factors associated with discharge in ED TIA encounters in 2021 showed patients from rural areas were more likely to be discharged (OR 2.95 (95% CI 2.42-3.59) than those in densely populated areas (OR 0.68 (95% CI 0.54-0.86). Conclusion: Discharge rates for patients with TIA increased between 2013 and 2021, with a parallel increase in the ED charges for patients discharged with TIA. Utilization of imaging in the ED increased during the time interval and may explain some of this increased cost. This may suggest a shifting of previously inpatient TIA evaluations to the non-admitted ED setting. Likelihood of discharge with a TIA was inversely related with population density of the patient’s location. More resources should be focused on optimizing ED evaluation and follow up of TIA patients in non-urban areas.