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Reuters Health story wisely notes limitations of NEJM study on treating mini-strokes


3 Star


Aggressive 'mini-stroke' therapy may cut serious stroke risk by half

Our Review Summary

hospital care stroke older adult

The story reports on a study, published in the New England Journal of Medicine, which reported that patients who had transient ischemic attacks (TIAs or mini-strokes) subsequently had a “lower-than-expected” incidence of serious strokes if they were treated at a hospital with a specialized TIA unit.

The study itself had significant limitations: There were a variety of interventions used at a large number of TIA units in many countries, but no control group or randomization. The TIA units were cherry-picked based on high volume of patients. All of the patients in the study received the best possible care–meaning that there was no comparable group of patients who could serve as a control. That’s good for the patients, but makes it difficult to judge what role the overall care played in limiting stroke risk and producing the “lower-than-expected” outcomes. And that’s perhaps the biggest weakness of the study: Its broad conclusion about typical outcomes versus what the study saw at TIA units. This comparison was made by looking at decade-old numbers on how many TIA patients typically go on to have serious strokes, but those numbers are outdated, since many treatments have evolved since then. And this was just one part of the study–it also looked at things like long-term medication adherence in patients treated at a TIA unit.

For a study as complicated as this, this brief story does a good job of describing the basics of the study, as well as some its limitations.


Why This Matters

Stroke is the fifth leading cause of death in the United States, with one American dying of stroke every four minutes, according to the CDC. In addition to this human cost, stroke is also estimated to cost the U.S. economy $34 billion each year. Given that broad impact, it makes sense to track research that informs the public–and health care providers–about developments related to stroke prevention, diagnosis and treatment. Even studies like this one, which offer limited evidence in support of more aggressive treatments offered by specialists, can have value in that context–as long as the related news stories recognize the limitations of the study and its findings.


Does the story adequately discuss the costs of the intervention?

Not Satisfactory

Cost isn’t addressed. Emergency room costs can be expensive, particularly for uninsured patients. And the costs associated with TIA treatment can vary widely, because treatment options can vary depending on the diagnosis. For example, a patient may be given drugs to “bust” a blood clot, or the patient may need to perform a surgical procedure. A 2014 study found that the average hospitalization for stroke in the U.S. cost approximately $20,396 ± $23,256.

That’s a lot of variability, and covers all types of stroke — not TIAs per se. In other words, it’s tricky to nail down any firm numbers for a relatively concise news story. But the costs associated with treatment in a TIA unit could still be discussed (or at least mentioned).

Does the story adequately quantify the benefits of the treatment/test/product/procedure?


The story satisfactorily quantified the benefits, by including relative and absolute reductions in stroke risks when patients are treated at a TIA unit. It also makes it clear that the measured benefits seen weren’t obtained via a comparative trial, but by looking at older data on stroke risks from TIA and comparing it to this newer set of data. (See quality of evidence criteria for why these benefits are shaky, though.)

Does the story adequately explain/quantify the harms of the intervention?

Not Satisfactory

The study doesn’t appear to discuss harms or side effects from this newer type of specialized stroke care for TIA patients, nor does the story. However, that doesn’t mean any exist. Aggressively treating TIAs carries risks and side effects.

Does the story seem to grasp the quality of the evidence?


This is a strong point for the story. It does an adequate job of describing the study, but what sets it apart is how it addresses some of the limitations of the study. First, the story notes that “[the study] didn’t include a comparison group, which would offer the best evidence.” Later, the story quotes an editorial that accompanied the paper in NEJM: “…this was not a randomized trial and there was no comparison group to assess whether specialized units performed better than nonspecialized (stroke) units…”. We are always happy to see stories that highlight a study’s weaknesses as well as its key findings. They also could have stressed how the numerous possible interventions given to patients at these TIA units also make it hard to draw conclusions about what actually helped.

However, we do want to note the story overlooked one important limitation: None of the hospitals in the study were actually in the U.S., calling into question the applicability of these study results for Americans. The story certainly could have raised this issue, especially since an American Heart Association spokesperson was quoted in the story.

Does the story commit disease-mongering?


No disease mongering here.

Does the story use independent sources and identify conflicts of interest?

Not Satisfactory

The story cites an independent expert source, as well as drawing on the third-party editorial published in NEJM. However, the story does not tell readers that the study was supported by pharmaceutical companies Sanofi and Bristol-Myers Squibb, which is an important oversight.

Does the story compare the new approach with existing alternatives?


The intervention in this story is sending patients to hospitals with specialized TIA units. The alternative–presumably being treated at a hospital without a TIA unit–wasn’t directly studied here, and this is made clear in the story.

However, we do wish the story had discussed if receiving care at one of these specialized units is really necessary, i.e., if similar care can be received at a regular hospital. As the study noted, it appears so: The researchers stated that these results “may be achievable in a large range of settings as long as patients are evaluated and treated for acute TIA and minor stroke on an urgent basis.”

Does the story establish the availability of the treatment/test/product/procedure?

Not Satisfactory

The story quotes from the NEJM editorial, which says “the widespread, systematic implementation of specialized TIA units across multiple sites, countries, and continents can make a difference in the care of these patients.”

However, it’s not clear how common these specialized TIA units are. Can they be found in any major hospital? Only in big cities or especially large medical centers? Only in a few of those medical centers? And is the “aggressive” treatment mentioned in the headline only available at these specialized TIA units, or can it be found in most emergency rooms? Readers are left in the dark on this one.

Does the story establish the true novelty of the approach?

Not Satisfactory

As with availability, we do wish the story had better explained to readers how novel a TIA unit is.

Does the story appear to rely solely or largely on a news release?


Because of the inclusion of independent sources, this story doesn’t appear to rely on a news release.

Total Score: 5 of 10 Satisfactory


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