Patients with ischemic stroke who receive care at hospitals with telestroke capacity are more likely to receive reperfusion therapy, and the 30-day mortality rate is lower than for those treated at hospitals that do not have a telestroke service, a new study shows.
Increases in rates of reperfusion treatment were largest in smaller hospitals, among rural residents, and among patients aged 85 years and older, the researchers found.
Dr Ateev Mehrotra
“This is a good-news message” that shows that reperfusion treatment now available worldwide “appears to be making a difference in saving lives,” study author Ateev Mehrotra, MD, associate professor, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.
“The question now is, how do we get this technology to smaller rural hospitals so that we can extend these benefits as far as we can,” he said.
The study was published online March 1 in JAMA Neurology.
The decision to administer reperfusion treatment is both time-sensitive and complex, the researchers note. Clinicians must rule out conditions that mimic stroke, identify contraindications to treatment, and appraise the expertise at the local hospital in comparison with the logistics and timing of a transfer to a tertiary center, the researchers note.
Although some hospitals have around-the-clock stroke expertise to rapidly evaluate patients with potential stroke, many do not.
That’s where a telestroke consultation comes in. This involves a real-time videoconference between a remotely located stroke specialist and a bedside healthcare professional in the emergency department (ED), as well as the patient.
The remote stroke expert can interview and examine the patient, review CT scans, determine candidacy for thrombolysis or thrombectomy, assess the need for transfer to a local teaching hospital for treatment within an appropriate time window, and recommend other treatments, including secondary stroke prevention.
“You’re bringing in the expertise you need quickly and efficiently to hospitals where it wasn’t available previously,” said Mehrotra.
The new study is the first national study to demonstrate the clinical benefits of telestroke. By its scope and design, it addresses some of the weaknesses of past studies, said Mehrotra. For one thing, it included use of thrombectomy, which was not commonly used until 2015.
For the study, researchers identified 76,636 ischemic stroke patients at 643 hospitals with telestroke capacity and matched them to the same number of patients at the thousands of hospitals across the country that did not have telestroke service, who served as controls. Patients were matched by individual characteristics such as age and sex and by hospital level characteristics, including the size of the hospital and the community.
The mean age of the patients was 78.8 years, and 57.7% were women.
A main outcome was receipt of reperfusion treatment, including administration of intravenous thrombolysis with alteplase or endovascular thrombectomy.
The study found that 6.8% of patients who underwent treatment at a hospital with telestroke capacity received reperfusion treatment, compared to 6.0% among those in the matched control group, an absolute difference of 0.78 percentage points (95% CI, 0.54 – 1.03; P < .001).
The risk ratio (RR) for receiving reperfusion was 13% higher in the treatment group than in the control group (RR, 1.13; 95% CI, 1.09 – 1.17; P < .001).
“This is substantial; it’s a really large difference for us clinically, and also translates into what we hope is improved outcomes,” said Mehrotra.
“When I started my career, we didn’t have much to offer, and now these reperfusion treatments open up the opportunity for reversing that blockage and saving those neurons, and that can mean a big difference between having lifelong disability vs not,” he said.
A subgroup analysis found sizable differences in reperfusion in low-volume hospitals.
“One of the most striking differences was that as you get to the smaller and smaller hospitals, we find the differences are larger, or the improvements in care that we see associated with telestroke are greater,” said Mehrotra.
He noted that providers at hospitals that don’t treat stroke frequently may be less familiar with ― and perhaps less likely to use ― new treatments, such as thrombectomy, or are less likely to be aware of evolving optimal time windows for treatment.
Although smaller hospitals and rural hospitals benefit most from telestroke, they’re the institutions least likely to have the service. “The question is, how to get telestroke in those sites?” said Mehrotra.
This, he added, might involve changing the current payment model to make the service more accessible. He noted that hospitals pay for telestroke capacity, often through a private company or local teaching hospital.
Roughly 30% of all hospital EDs in the United States now use telestroke technology.
The study also showed that the increase in reperfusion treatment at telestroke hospitals was greatest for patients older than 85 years.
“Our hypothesis is that emergency medicine physicians are less comfortable using thrombolysis on older patients because of the many contraindications, so having that stroke neurologist saying, ‘Yes, that’s a good idea,’ may lead to greater reperfusion treatment in the oldest population,” said Mehrotra.
Another main outcome was mortality. The analysis showed that the mortality rate at 30 days was lower in the telestroke group than in the control group (13.1% vs 13.6%; difference, 0.50 percentage points; 95% CI, 0.17 ― 0.83, P = .003).
However, Mehrotra cautioned that the effect size was small, that it was not evident at 6 months, and that it may have been driven by unmeasured factors, such as stroke severity.
“As you go farther and farther out from the actual stroke, the difference in mortality starts to shrink, so it goes from a 5% reduction down to a 2% reduction in mortality by 6 months,” said Mehrotra.
This could be because people with stroke have other medical problems, he added. “We might save them from the stroke, but another medical issue emerges that leads to their unfortunate demise.”
To assess patient disability and functional status, the researchers used a validated measure that captures patient days spent living in the community in the 90 days following discharge.
“We thought maybe telestroke would lead to fewer people needing nursing home care, but in the short term, we didn’t see that difference,” said Mehrotra.
There were also no differences with regard to return to hospital or in spending (which included total payments for inpatient, outpatient, and skilled nursing facility stays, hospice, and home health agency services).
But a “key caveat” with spending, said Mehrotra, is that the researchers assessed spending from the perspective of the insurer (Medicare), so the telestroke fee was not included.
Because a randomized clinical trial comparing telestroke care with placebo is unlikely, given the ethics of not offering stroke patients effective treatments, the authors said this new “rigorous observational study” likely provides the “best evidence” for the remote stroke service.
A limitation of the study is that important patient factors, such as symptom onset, were not available in the data. Also, hospitals that introduce telestroke capacity may be more committed to quality improvement, and this, rather than telestroke, could be driving differences.
Commenting on the study for Medscape Medical News, telestroke physician Alicia Zha, MD, assistant professor of neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas, Houston, Texas, thought it was “really elegantly designed.”
Zha said she was particularly impressed with the authors’ efforts “to get around the limitations of an administrative dataset.”
She said she was surprised that the effect for reperfusion wasn’t larger and suspects it may have been “diluted” by “natural changes in practice patterns” over the time of the study.
It would be interesting to see whether the changes in effect size would be found if such a study were conducted 10 years from now, when more hospitals will be using thrombectomy, said Zha.
She praised the subanalyses that evaluated effects of age and different hospital locations, and appreciated the focus on smaller centers.
Because criteria for using reperfusion therapy are “always changing,” Zha said she “would not expect an emergency department doctor to be able to keep up” with all the evolving developments.
“There are a lot of borderline cases these days, and having that extra stroke expertise is definitely helpful,” she said.
The study received support from the National Institute of Neurological Disorders and Stroke. Mehrotra and Zha report no relevant financial relationships.
JAMA Neurol. Published online March 1, 2021. Abstract
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