No Stroke Expertise? Specialist on Speed Dial Boosts Outcomes

 Oh God, 'better care'! The tyranny of low expectations in full display. Aren't you glad your doctors and researchers are OK with this lazy crapola? Massive amounts of chest thumping for what should be regular care. When you get to 100% recovery then you can celebrate, until then just shut up and do your job, which is 100% recovery in case you missed that goal.

No Stroke Expertise? Specialist on Speed Dial Boosts Outcomes

Stroke care compared between hospitals with and without telestroke technology

by Nicole Lou, Staff Writer, MedPage Today March 1, 2021

Stroke patients received better care at hospitals lacking on-site stroke expertise if they had telestroke capacity, according to large observational study.

Reperfusion treatment, through thrombolysis or thrombectomy, was more likely among acute ischemic stroke patients at telestroke centers compared with matched peers treated without either on-site or virtual capacity (6.8% vs 6.0%, RR 1.13, 95% CI 1.09-1.17), reported Ateev Mehrotra, MD, MPH, of Harvard Medical School, and colleagues in a paper published online in JAMA Neurology.

Telestroke made the biggest difference for rural patients and the lowest-volume hospitals (admitting fewer than two strokes per month), whereas higher-volume centers (averaging at least two strokes per week) showed no improvement in reperfusion therapy by telestroke capacity.

Approximately 30% of all hospitals emergency departments in the U.S. now use telestroke technology. Although low-volume and rural hospitals showed the greatest benefits of telestroke, they were least likely to have telestroke capacity in the study.

Better reimbursement or direct financial support may encourage these hospitals to adopt telestroke, Mehrotra's team suggested, noting that barriers to adoption may include insufficient financial investment, lack of high-speed internet in rural communities, and regulations that limit financial support from tertiary hospitals.

Mehrotra's group also showed higher reperfusion rates at telestroke centers among patients 85 years and older, for whom emergency medicine physicians may be uncomfortable using thrombolysis given the associated increased risk of intracerebral hemorrhage in the oldest age group.

Telestroke extends stroke expertise to hospitals without on-site stroke expertise, where emergency departments are staffed by people with less exposure to stroke care and thus lower comfort levels with reperfusion decisions. Remote consultations permit contact between a stroke specialist, the bedside care provider, and the patient.

Study investigators compiled Medicare data on acute stroke admissions in the U.S. in which the patient had first presented to a hospital without on-site stroke expertise in 2008-2017. They found 76,636 matched pairs of patients (57.7% women, mean age 78.8 years) going to hospitals with or without telestroke.

There was no evidence that stroke care had previously been superior at hospitals that eventually adopted telestroke.

Mortality rates at 30 days favored stroke patients at telestroke-capable hospitals (13.1% vs 13.6%, RR 0.96, 95% CI 0.94-0.99). However, the effect dissipated by 6 months (22.6% vs 23.0%, RR 0.98, 95% CI RR 0.97-1.00).

The two groups had similar healthcare costs (institutional spending $26,560 vs $26,524) and functional status (60.25 vs 60.22 days alive in the community after discharge) through 90 days.

"To our knowledge, this is the first study to demonstrate that telestroke is associated with a clinically meaningful reduction in mortality and improved use of reperfusion treatments with no increase in health care spending," Mehrotra and colleagues noted.

"Though cost-effective from the perspective of Medicare, it is important to emphasize that local hospitals must pay for telestroke capacity, and these payments are not captured in our data," they cautioned.

Other limitations of the study include unobserved confounding, the lack of data on symptom onset and other patient factors in Medicare records, and the reliance on community living as a proxy measure of functional outcome after stroke.

"Given the increasing prevalence of telestroke in EDs and current state of evidence, it is unlikely that a randomized clinical trial of telestroke vs placebo is feasible given the ethics of not offering patients effective stroke care. Therefore, we believe this form of rigorous observational study is likely to be the best evidence available on the association of telestroke with treatment and outcomes for patients with acute ischemic stroke," study investigators wrote.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The study was supported by a grant from the National Institute of Neurological Disorders and Stroke.

Mehrotra had no disclosures.

Study coauthors reported ties to Genentech, Life Image, the Massachusetts Department of Public Health, Penumbra, Diffusion Pharma, the Agency for Healthcare Research and Quality, Controlled Risk Insurance Company, and the American College of Emergency Physicians.

Primary Source

JAMA Neurology

Source Reference: Wilcock AD, et al "Reperfusion treatment and stroke outcomes in hospitals with telestroke capacity" JAMA Neurol 2021; DOI: 10.1001/jamaneurol.2021.0023.