Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity.

Importance Telestroke is increasingly used in hospital emergency departments, but there has been limited research on its impact on treatment and outcomes. Objective To describe differences in care patterns and outcomes among patients with acute ischemic stroke who present to hospitals with and without telestroke capacity. Design, Setting, and Participants Patients with acute ischemic stroke who first presented to hospitals with telestroke capacity were matched with patients who presented to control hospitals without telestroke capacity. All traditional Medicare beneficiaries with a primary diagnosis of acute ischemic stroke (approximately 2.5 million) who presented to a hospital between January 2008 and June 2017 were considered. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Hospitals included short-term acute care and critical access hospitals in the US without local stroke expertise. In 643 hospitals with telestroke capacity, there were 76 636 patients with stroke who were matched 1:1 to patients at similar hospitals without telestroke capacity. Data were analyzed in July 2020. Main Outcomes and Measures Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge. Results In the final sample of 153 272 patients, 88 386 (57.7%) were female, and the mean (SD) age was 78.8 (10.4) years. Patients cared for at telestroke hospitals had higher rates of reperfusion treatment compared with those cared for at control hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI, 0.54-1.03; P < .001) and lower 30-day mortality (13.1% vs 13.6%; difference, 0.50 percentage points; 95% CI, 0.17-0.83, P = .003). There were no differences in days spent living in the community following discharge or in spending. Increases in reperfusion treatment were largest in the lowest-volume hospitals, among rural residents, and among patients 85 years and older. Conclusions and Relevance Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and have lower 30-day mortality.

[1]  Eric E. Smith,et al.  Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. , 2020, JAMA.

[2]  L. Schwamm,et al.  Assessment of Telestroke Capacity in US Hospitals. , 2020, JAMA neurology.

[3]  C. Camargo,et al.  Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States , 2019, Journal of the American Heart Association.

[4]  Eric E. Smith,et al.  Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients With Atrial Fibrillation and Ischemic Stroke: Findings From the Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. , 2019, JAMA neurology.

[5]  R. Zorowitz,et al.  Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. , 2019, Stroke.

[6]  D. Hess,et al.  Impact of Participation in a Telestroke Network on Clinical Outcomes: Evidence From the Georgia Coverdell Acute Stroke Registry , 2019, Circulation. Cardiovascular quality and outcomes.

[7]  C. Camargo,et al.  A national survey of telemedicine use by US emergency departments , 2020, Journal of telemedicine and telecare.

[8]  Guijing Wang,et al.  Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas. , 2018, Health affairs.

[9]  A. Demchuk,et al.  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging , 2018, The New England journal of medicine.

[10]  M. Chen,et al.  Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct , 2018, The New England journal of medicine.

[11]  Giancarlo Visconti,et al.  Handling Limited Overlap in Observational Studies with Cardinality Matching , 2021 .

[12]  Bart M Demaerschalk,et al.  AHA Scientific Statement , 2022 .

[13]  Eric E. Smith,et al.  Hospital Variation in Home-Time After Acute Ischemic Stroke: Insights From the PROSPER Study (Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research) , 2016, Stroke.

[14]  Eric E. Smith,et al.  Use and Outcomes of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients ≥90 Years of Age , 2016, Stroke.

[15]  L. Schwamm,et al.  Telestroke—the promise and the challenge. Part one: growth and current practice , 2016, Journal of NeuroInterventional Surgery.

[16]  Eric E. Smith,et al.  Assessment of Home-Time After Acute Ischemic Stroke in Medicare Beneficiaries , 2016, Stroke.

[17]  Eric E. Smith,et al.  Randomized assessment of rapid endovascular treatment of ischemic stroke. , 2015, The New England journal of medicine.

[18]  Eric E. Smith,et al.  Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke: Use, Temporal Trends, and Outcomes , 2015, Stroke.

[19]  Hester F. Lingsma,et al.  A randomized trial of intraarterial treatment for acute ischemic stroke. , 2015, The New England journal of medicine.

[20]  Christopher S. Coffey,et al.  2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment , 2015 .

[21]  P. Sandercock,et al.  Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials | NOVA. The University of Newcastle's Digital Repository , 2014 .

[22]  Paul R. Rosenbaum,et al.  Matching for Balance, Pairing for Heterogeneity in an Observational Study of the Effectiveness of For-Profit and Not-For-Profit High Schools in Chile , 2014, 1404.3584.

[23]  Eric E. Smith,et al.  Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines–Stroke Hospitals , 2013 .

[24]  Zhenzhen Xu,et al.  A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial , 2013, The Lancet Neurology.

[25]  Anand Viswanathan,et al.  The Status of Telestroke in the United States: A Survey of Currently Active Stroke Telemedicine Programs , 2012, Stroke.

[26]  W. A. Maggiore Stroke of the clock: 'time is brain' when treating stroke patients. , 2012, JEMS : a journal of emergency medical services.

[27]  Kimberly S. Maier,et al.  Patient-Level and Hospital-Level Determinants of the Quality of Acute Stroke Care: A Multilevel Modeling Approach , 2010, Stroke.

[28]  J. Kalbfleisch,et al.  Attitudes and Beliefs of Michigan Emergency Physicians Toward Tissue Plasminogen Activator Use in Stroke: Baseline Survey Results From the INcreasing Stroke Treatment through INteractive behavioral Change Tactic (INSTINCT) Trial Hospitals , 2010, Stroke.

[29]  D. Cutler,et al.  Trends in thrombolytic use for ischemic stroke in the United States. , 2010, Journal of hospital medicine.

[30]  Gregory W Albers,et al.  Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials , 2010, The Lancet.

[31]  Rebecca A Betensky,et al.  Remote Supervision of IV-tPA for Acute Ischemic Stroke by Telemedicine or Telephone Before Transfer to a Regional Stroke Center Is Feasible and Safe , 2010, Stroke.

[32]  P. Rosenbaum Design of Observational Studies , 2009, Springer Series in Statistics.

[33]  Mary G. George,et al.  Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. , 2009, Stroke.

[34]  M. Kaste,et al.  Telestroke Networking Offers Multiple Benefits beyond Thrombolysis , 2009, Cerebrovascular Diseases.

[35]  M. Kaste,et al.  Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. , 2008, The New England journal of medicine.

[36]  M. Walters,et al.  Time Spent at Home Poststroke: “Home-Time” a Meaningful and Robust Outcome Measure for Stroke Trials , 2008, Stroke.

[37]  P. Heuschmann,et al.  Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany , 2006, The Lancet Neurology.

[38]  J. Saver Time Is Brain—Quantified , 2006, Stroke.

[39]  Iva Petkovska,et al.  Virtual TeleStroke support for the emergency department evaluation of acute stroke. , 2004, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[40]  Joseph P Broderick,et al.  Eligibility for Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke: A Population-Based Study , 2004, Stroke.

[41]  Joseph P. Broderick,et al.  Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1995 .

[42]  A Cappello,et al.  Model selection for ventricular mechanics: a sensitivity analysis approach. , 1987, Journal of biomedical engineering.