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Telestroke capabilities may extend stroke expertise to hospitals without on-site stroke experts.
Patients with ischemic stroke treated at hospitals with telestroke capacity are more likely to receive reperfusion treatment and have lower 30-day mortality.
Telestroke has the potential to extend stroke expertise to hospitals without on-site stroke expertise. Consultations consist of a real-time videoconference between the patient, remotely located stroke specialist, and a bedside healthcare professional in the emergency department.
Andrew Wilcock, Ph.D., and colleagues described differences in care patterns and outcomes among patients with acute ischemic stroke who presented to hospitals with and without telestroke capacity. The team focused only on patients presenting to a hospital without on-site stroke expertise. They matched patients with acute ischemic stroke who presented to a hospital who recently introduced telestroke capacity to control patients who presented to a hospital without telestroke. Matches were done 1:1 based on hospital and patient characteristics.
The investigators used 100% Medicare Inpatient and Outpatient Standard Analytic Files to identify all acute stroke admissions in the U.S. within the traditional fee-for-service Medicare program from January 2008 to June 2017. Admissions included inpatient or outpatient emergency department/observation stays in short-term acute care or critical access hospital. Patients had a primary diagnosis of acute ischemic stroke.
Wilcock and the team measured receipt of reperfusion treatment through administration of intravenous thrombolysis with alteplase or endovascular thrombectomy using procedure and diagnosis codes. They used the date of death field from the beneficiary summary files to create indicators for mortality seven, 30, 90, and 180 days from admission.
Overall, the team identified more than 369,000 stroke episodes that met their patient and hospital inclusion criteria. Of those, 87.338 patients received care at one of 643 hospitals with telestroke capacity. Prior to matching, those treated at a hospital with telestroke capabilities were more likely to live in an urban area and have hyperlipidemia and diabetes. They matched 76,636 telestroke admissions to controls. In the final sample, 57.7% were female and the mean age was 78.8 years old.
Among those treated initially at a hospital with telestroke capability and their matched controls, 6.8% and 6%, respectively, received reperfusion treatment (absolute difference, .78 percentage points; 95% CI, .54-1.03; P <.001). In a comparison with their matched controls, the risk ratios for treatment were higher for patients cared for at telestroke hospitals for any reperfusion treatment (RR, 1.13; 95% CI, 1.09-1.17; P <.001), drip-and-ship cases (RR, 1.38; 95% CI, 1.3-1.45; P <.001), and thrombectomies (RR, 1.42; 95% CI, 1.25-1.62; P <.001).
There was lower mortality (13.1% vs 13.6%; difference, .5 percentage points; 95% CI, .17-.83; P=.003) at 30 days from admission. For postadmission mortality, the risk ratios were .95 (95% CI, .92-.99; P = .02) at seven days, .96 (95% CI, .94-.99; P = .003) at 30 days, .98 (95% CI, .96-1; P = .04) at 90 days, and .98 (95% CI, .97-1; P = .09) at 180 days.
The team found no significant differences between telestroke and control patients for returns to the hospital, spending, and living in the community.
The study, “Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity,” was published online in JAMA Neurology.