Bridge to Better Care: Investigating Transient Ischemic Attack (TIA) Management Expertise Among Primary Healthcare Providers in Al-Ahsa, Saudi Arabia

Introduction Transient ischemic attacks (TIAs) are brief episodes of neurological impairment caused by reduced blood flow to the brain, spinal cord, or retina, typically lasting under an hour. Recent advances in neuroimaging suggest that some TIAs may actually be small strokes with resolved symptoms. This study focuses on assessing the knowledge and management of TIAs among primary care physicians and nurses in Al-Ahsa, Saudi Arabia. Methodology This is a cross-sectional study, conducted in Al-Ahsa, Saudi Arabia, during the period July to August 2023. Data were collected using an electronic questionnaire and was analyzed using IBM SPSS Statistics for Windows, version 27.0.1 (released 2020, IBM Corp., Armonk, New York, United States). Results Among the participants, 64.0% correctly identified TIA as an ischemic neurological deficit. However, only 20.2% provided correct responses for all TIA symptoms. Regarding diagnostic tests, 47.4% acknowledged the need for neuroimaging immediately after TIA, while 17.5% recognized the importance of ultrasonography of the supra-aortic trunks. In terms of TIA management, 38.6% preferred referral to the emergency service, and 41.2% correctly perceived the risk of TIA recurrence as similar to that of established cerebral ischemic stroke. Significant disparities were observed in the recognition of TIA symptoms, with physicians outperforming nurses, particularly in identifying motor deficits (82.4% vs. 65.2%) and speech alterations (86.8% vs. 76.1%, p = 0.004). However, nurses exhibited better knowledge in recognizing the need for a neuroimaging test (48.5% vs. 45.7%, p = 0.849) and the urgency of conducting a transcranial Doppler (TCD) (19.1% vs. 23.9%, p = 0.641). Conclusion A considerable proportion of healthcare providers demonstrate a good understanding of TIA definition and management. However, the lack of significant predictors for good knowledge and attitude suggests the need for more comprehensive strategies to enhance TIA management expertise across healthcare professionals.


Introduction
A transient ischemic attack (TIA) is an episode of temporary neurologic impairment that comes from focal ischemia of the brain, spinal cord, or retina but does not include acute tissue infarction.It usually lasts less than an hour [1].Advances in neuroimaging imply that many of these cases may represent small strokes with resolved symptoms rather than true TIAs, although the traditional definition of TIA includes symptoms lasting as long as 24 hours [2].
Both TIA and small ischemic stroke are linked to brain malfunction in a specific location brought on by a localized decrease in blood flow and manifested as either temporary or insignificant clinical symptoms [3].
The available estimated yearly incidence rates of TIA in Western countries range from 29.0 to 61.0 cases per 100,000 [4,5].With risk estimates within three months ranging from 7.5% to 17.3%, TIA is a recognized predictor of future ischemic stroke [6,7].The better identification and management of vascular risk factors may have modified TIA epidemiology in recent years [8].
The American Society of Anesthesiologists (ASA)'s most recent recommendations classify risk variables using an evidence-based methodology and with some flexibility: age, sex, race, and significant family history are non-modifiable; tobacco use, obesity, physical inactivity, cardiovascular disease, atrial fibrillation, diabetes mellitus, arterial hypertension, and peripheral arterial disease are well documented and modifiable; and migraine history, obstructive sleep apnea, sleep patterns, and high-risk alcohol consumption are potentially modifiable [9,10].
Given the fact that TIA signs and symptoms are transient, less accurate than those in patients with stroke who present with well-established clinical presentation, the diagnosis of TIA might be challenging [11].
The signs and symptoms of TIA are manifested based on the vascular supply of the affected area.Eighty percent of TIAs and strokes occur in the anterior circulation, which carries about 80% of cerebral blood flow [12].The anterior circulation of the brain is a branch of the internal carotid artery.Anterior circulation branches off further to give anterior and middle cerebral arteries and their tributaries.The remaining 20% of brain areas are supplied by posterior circulation, which is formed by the two vertebral arteries that combine to give rise to the basilar artery.Thus, 20% of TIAs affect these vertebrobasilar territories [13].
The clinical manifestations of TIA include hemiparesis and other types of motor dysfunction, being the most common presentation; somatosensory symptoms; dysarthria and/or aphasia; monocular blindness, i.e, amaurosis fugax resulting from an occlusion in of the ophthalmic arteries, which receive their blood supply directly from internal carotid artery; hemivisual field defects; dizziness; diplopia accompanied or preceded by posterior circulation-suggestive symptoms, such as vertigo, dysarthria or ataxia, headache, limb shaking, and other involuntary movements; cognitive and emotional symptoms; and loss of consciousness or syncope [11].
Up to 20% of TIA patients proceed to ischemic stroke.Thus, a proper identification of TIA signs and symptoms and rapid assessment by primary care physicians are crucial [14].In this study, we aim to assess the knowledge and management of TIAs among primary care physicians and nurses in Al-Ahsa, Saudi Arabia, through a survey.

Materials And Methods
The study was approved by the Research Ethics Committee at King Fahad Hospital Hofuf, Saudi Arabia, on November 2023 (approval no.58B-EP-2023).

Statistical analysis
Both descriptive and inferential statistical analyses of the data were carried out.Simple descriptive statistics of the sociodemographic characteristics and other categorical variables in the form of frequencies and percentages were calculated and tabulated.For continuous variables, means and standard deviations were reported as measures of central tendency and dispersion, respectively.
For the seven questions assessing knowledge of TIA, a score of 1 was assigned for each correct response, and the total score of each participant was calculated.A score of 4 or greater was considered as good knowledge.Furthermore, referral to the emergency department to carry out an urgent CT scan was considered good attitude.
Both univariate and multivariate inferential statistical analysis was performed.Univariate analysis involved using Fischer's exact test for categorical variables and independent samples t-test for continuous variables.Multivariate analysis was done through binary logistic regression to identify predictors of good knowledge and attitude toward TIA patients.
Significance was established at a p-value of 0.05 or less, indicating a 95% confidence interval (CI).All statistical calculations were performed using IBM SPSS Statistics for Windows, version 27.0.1 (released 2020; IBM Corp., Armonk, New York, United States).

Survey responses
Regarding the definition of TIAs, 64.0% (N = 73) correctly identified it as an ischemic neurological deficit lasting less than one hour or a transient deficit lasting less than 24 hours.While the participants recognized various TIA symptoms, only 20.2% (N = 23) provided correct responses for all.
Regarding TIA management, 38.6% (N = 44) preferred referral to the emergency service, while 41.2% (N = 47) correctly perceived the risk of TIA recurrence as similar to that of established cerebral ischemic stroke.In total, 22.8% (N = 26) demonstrated good knowledge of TIA management, and 21.1% (N = 24) exhibited a positive attitude toward referring patients for a CT scan in an emergency (     In Table 3, age was not significantly associated with good TIA knowledge (p = 0.380), as indicated by the mean age of 32.2 years for those with less than four correct responses and 30.7 years for those with greater than or equal to four correct responses.However, a significant difference was observed in the definition of TIA knowledge (p = 0.029*), with those aged 30.4 years among those with good knowledge, compared to 34.8 years among those without.In addition, the participants in the 20-29-year age category showed a significantly higher likelihood of having a good understanding of TIA symptoms (55.3%) (N = 26) compared to the other age groups (p = 0.030*).

Variables associated with correct knowledge of TIA among doctors
Regarding gender, there were no significant differences in TIA knowledge between male and female doctors.
In terms of years of practice, no significant associations were found between the duration of practice and TIA knowledge in the variables assessed.In Table 5 and Table 6, the analysis revealed that there were no statistically significant differences in TIA knowledge among nurses based on gender, years of practice, or the majority of age categories.However, a significant difference was observed regarding knowledge of neuroimaging among different ages.Specifically, younger nurses (mean age = 31.97,SD = 7.0) displayed better knowledge of neuroimaging compared to their older counterparts (mean age = 38.4,SD = 10.1;p = 0.014).For the prediction of good knowledge of TIA, the analysis indicates that age (p = 0.081, AOR = 0.908, 95% CI: 0.815-1.012) is not a significant predictor.Gender, years of practice, and professional background (doctors relative to nurses) also do not appear to be significant factors influencing good knowledge of TIA.However, for individuals with more than 10 years of experience (p = 0.073, AOR = 4.738, 95% CI: 0.863-26.009),there is a trend toward higher odds of having good knowledge compared to those with less than five years of experience, although this trend did not reach statistical significance.

Predictors of correct knowledge and management of TIA
In the context of good attitude toward TIA, the analysis again demonstrates that age (p = 0.605, AOR = 0.973, 95% CI: 0.877-1.079)does not significantly influence attitudes.Gender (p = 0.639, AOR = 1.272, 95% CI: 0.465-3.484)also does not appear to be a significant predictor of good attitude.Similarly, years of practice do not significantly impact attitudes.However, doctors, when compared to nurses (p = 0.288, AOR = 1.777, 95% CI: 0.615-5.137),exhibit a trend toward higher odds of having a good attitude, although this trend is not statistically significant.
When looking at the predictions separately for doctors and nurses, similar trends were observed in both groups, with no significant predictors for good knowledge and attitude among doctors or nurses based on age, gender, or years of practice.
In summary, the analysis suggests that the factors of age, gender, years of practice, and professional background do not significantly predict good knowledge and attitude toward TIA among the studied cohort of doctors and nurses.Further research and larger sample sizes may be necessary to draw more definitive conclusions regarding these predictors.

Discussion
Our study shed light on the knowledge and practices of healthcare providers regarding TIA management.
The study revealed notable sociodemographic differences between doctors and nurses.Doctors were generally younger and more likely to be male, while nurses were slightly older and predominantly female.These differences could influence their approach to TIA management, emphasizing the need for targeted educational interventions.The majority of both doctors and nurses demonstrated a reasonable understanding of the definition of TIA, which suggests that both groups have a solid grasp of the basic definition of TIA [15].A significant proportion of participants demonstrated a correct understanding of TIA in terms of duration and symptoms.However, there is room for improvement, particularly regarding knowledge of diagnostic tests and appropriate management strategies.In general, doctors and nurses exhibited differences in their understanding of TIA management.
Doctors showed a better understanding of TIA symptoms, especially motor deficits and speech alterations, which indicates that doctors have more comprehensive training in recognizing the clinical manifestations of TIA and also highlighting the need for further education for nurses in this aspect [14].Nurses exhibited a relatively stronger understanding of the need for neuroimaging tests and the urgency of conducting a TCD, as also evident by a study providing importance of TCD in acute stroke, conducted by Sharma et al. ( 2008) [16].This suggests that nurses may be more attuned to the diagnostic aspects of TIA evaluation, possibly due to their roles in patient assessment and care coordination, suggesting potential areas for improving doctors' awareness in these domains [16].There is a notable gap in the understanding of the urgency of neuroimaging immediately after a TIA event, emphasizing the necessity for increased awareness and education [17].
Doctors were more inclined to refer TIA patients to emergency services, underscoring their proactive approach to urgent care.However, there is a need to align practices with established guidelines [18].Both doctors and nurses displayed similar attitudes toward the risk of TIA recurrence, with no significant differences observed.This suggests that both groups perceive the risk of TIA recurrence similarly, which is a positive aspect as it reflects a unified understanding of the condition's potential severity [19].
Age was not a significant factor in determining TIA knowledge among doctors.However, there was a noteworthy difference in the understanding of TIA symptoms, with younger doctors having a significantly better grasp of TIA symptoms compared to other age groups.This suggests that younger doctors may have received more recent training or education on TIA symptoms [20].No significant differences in TIA knowledge between male and female doctors were found, indicating that gender does not play a role in TIArelated knowledge among this group of healthcare providers.Interestingly, the duration of practice did not show significant associations with TIA knowledge among doctors.This suggests that regardless of their years of experience, doctors in the study had similar levels of TIA knowledge [21].
Similarly, among nurses, age did not significantly impact TIA knowledge, except for knowledge related to neuroimaging.Younger nurses demonstrated better knowledge of neuroimaging compared to their older counterparts.This may be due to younger nurses having received more up-to-date training in this area [22].
When considering both doctors and nurses together, the study found that age, gender, and years of practice did not significantly predict good knowledge or a positive attitude toward TIA.This implies that regardless of their age, gender, or years of experience, there is a relatively consistent baseline level of TIA knowledge and attitudes among the studied healthcare professionals.This finding suggests that factors beyond demographic characteristics play a more significant role in shaping their knowledge and attitudes [23].However, individuals with more than 10 years of experience showed a trend toward higher odds of having good TIA knowledge.
Similarly, doctors exhibited a trend toward a more positive attitude compared to nurses.It suggests that a longer duration of practice may provide healthcare providers with additional exposure to TIA cases and clinical scenarios, leading to a deeper understanding of the condition over time [24].This could indicate that experience is an important factor in acquiring expertise in TIA management [25].
The study has several limitations that should be acknowledged.The sample size of 114 participants, while informative, may not fully represent the entire healthcare workforce in the region.In addition, this research relies on self-reported survey responses, which are subject to recall bias and social desirability bias [26].Furthermore, this study predominantly focuses on healthcare providers in one specific region, which may limit the generalizability of the results to other healthcare settings or regions with different healthcare infrastructure and resources.

Conclusions
This study highlights the differences in understanding and practices between doctors and nurses, emphasizing the need for targeted educational interventions.Despite the identified gaps, a considerable proportion of healthcare providers demonstrate a good understanding of TIA definition and management.However, the lack of significant predictors for good knowledge and attitude suggests the need for more comprehensive strategies to enhance TIA management expertise across healthcare professionals.Further research with larger and more diverse samples, encompassing a wider geographic area, is essential to better comprehend the factors influencing TIA management and design effective interventions to bridge the existing gaps in care.

TABLE 2 : Survey responses and differences between doctors and nurses
*P < 0.05, significant; F: Fischer's exact test

Table 3
present the variables associated with good TIA knowledge among doctors, with a focus on different aspects of their knowledge and demographics.

TABLE 3 : Variables associated with good TIA knowledge among physicians
a. Position/Title = Physician; F: Fischer's exact test, t: independent samples t-test; TIA: transient ischemic attack

Table 4
examines knowledge associations related to ultrasound studies of the supra-aortic trunks, TCD, management of TIA patients, and recurrence of TIA among doctors.Similar to Table5, age did not significantly affect knowledge in these categories.Gender and years of practice also did not show significant associations with TIA knowledge in these areas.

TABLE 4 : Variables associated with good TIA knowledge among physicians
a. Position / Title = Physician; F: Fischer's exact test; t: independent samples t-test; TIA: transient ischemic attack

Table 5
and Table6present variables associated with good TIA knowledge among nurses, focusing on TIA management, definition, symptoms, neuroimaging, ultrasound studies of the supra-aortic trunks, TCD, management of patients with TIA, and recurrence after TIA.P value F/

TABLE 6 : Variables associated with good TIA knowledge among nurses
a. Position/Title = Nurse; F: Fischer's exact test; t: independent samples t-test; TIA: transient ischemic attack

Table 7
presents the predictors of good knowledge and attitude regarding TIA among the studied cohort, which includes both doctors and nurses.The table reports the p-values, adjusted odds ratios (AORs), and their corresponding 95% CIs for several factors.