Background

According to recently published data, only 55% percent of Americans reside within one hour of a primary stroke center.

Patients in rural areas of the country often live further away; this geographic barrier renders them unable to access appropriately trained physicians within a reasonable time frame for employment of recombinant tissue plasminogen activator (rt-PA) therapy after a stroke.

In fact, patients presenting to rural emergency departments are 10 times less likely to receive rt-PA therapy after an acute ischemic event, profoundly affecting patients outcomes.

The gap in access experienced by rural patients can be bridged by telemedicine. It allows for immediate, direct access to stroke specialists regardless of physical proximity, saving time crucial for ensuring that rt-PA can be used safely. The reliability of telemedicine in evaluating stroke patients has been previously published: the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trials.

Accuracy of the recommended treatment plan was shown to be significantly higher utilizing telemedicine than solely voice communications. Contrastingly, a replication of the STRokE DOC study conducted in Arizona found that telephone communication outperformed telemedicine in decision-making accuracy, although the difference was insignificant. Both original studies concluded that “whether by telemedicine or telephone, there were appropriate treatment decisions, high rt-PA utilization rates, and low ICH (intracranial hemorrhage) complications.”

Study results

Demaerschalk et al. recently published an analysis of the pooled results of these two trials. These trials were prospectively randomized and were “conducted in a multistate hub and spoke telestroke network setting with acute stroke syndrome patients, comparing telemedicine versus telephone-only consultations.” Through the evaluation of 276 patients, the authors found that correct decisions regarding eligibility of rt-PA thrombolytic therapy were made significantly more often with telemedicine consultations than by telephone (96% telemedicine, 83% telephone).

Additionally, IV rt-PA usage was higher in the telemedicine group while ninety-day outcomes and ICH rates were no different, though telemedicine consultations were eight minutes longer on average.

Conclusions

Currently, eight hundred hospitals in the U.S. are supported by telestroke networks; as implementation barriers continue to fall, the authors expect this number to soar in coming years. Incentivization of medical practitioners through on-call stipends and education of health professions students can assert the value of telemedical evaluations for stroke patients. The authors have previously shown telestroke networks to be a cost effective solution to a complex and expensive issue, motivating insurers to adjust reimbursement rates to reflect these conclusions.

Although results were not identical between both studies, the original STRokE DOC trial was successfully replicated in Arizona, speaking the generalizability of the studied telemedicine implementation. Furthermore, considering the comparability of telephonic evaluations with regards to patient outcomes, a consistent backup would be available in the event of technological failure precluding telemedicine functions.  However, the authors unequivocally assert that telemedicine interventions are preferable in light of their results.

Access barriers continue to plague the rural poor in the U.S.; transportation time and cost is a luxury that most cannot afford. Specialty services in rural areas are additionally limited, profoundly impacting patient outcomes during emergencies where rapid decisions are vital to ensure good outcomes. Telemedicine continues to prove its worth by removing geographic and temporal access barriers to acute specialty care; in the case of stroke, removal of such impediments is not an exercise of convenience but rather exerts significant effects on patient morbidity and mortality.

 

Authors: Bart M. Demaerschalk, M.D., M.Sc., FRCP(C), Rema Raman, Ph.D., Karin Ernstrom,
and Brett C. Meyer, M.D.

Institutions: Department of Neurology, Mayo Clinic, Phoenix, Arizona. Departments of Neurosciences and Family and Preventive Medicine, University of California San Diego School
of Medicine, San Diego, California.

Original Abstract: PubMed