Implementing Telestroke May Not Change Stroke Systems of Care

(Reuters Health) – Adoption of telestroke essentially had no impact on mean stroke volume in hospitals that used the technology, a U.S. study suggests.

An analysis of Medicare data from 2008 to 2018 found that telestroke had no impact on the number of patients coming to hospitals using the technology, nor on ambulance transport distance, case mix, interhospital transfers or bed size of receiving hospitals among transferred patients, according to the report published in JAMA Network Open.

“The bottom line is that we did not find significant changes in the organization of stroke systems of care with telestroke implementation at a hospital,” said the study’s first author, Dr. Kori Zachrison, an associate professor of emergency medicine at the Massachusetts General Hospital and Harvard Medical School in Boston.

“This was true for the hospitals’ own catchment area, for their case mix, for their transfer rates, and for the destination hospitals of transferred patients,” Dr. Zachrison said. “Telestroke is a really valuable tool to improve the care of patients with stroke who present to EDs without other access to stroke expertise. And so, we hoped that we would see it lead to a change in patient allocation in the system.”

Dr. Zachrison said she was surprised by the findings. “We hoped that…patients would more frequently present to hospitals introducing telestroke capability, and that patients might be able to more frequently stay in their own communities for stroke care rather than being transported longer distances initially or transferred to hospitals farther from their homes and support networks,” she said.

The findings do not “say anything about the value or effectiveness of telestroke itself,” Dr. Zachrison said. “There is a lot of good strong prior research establishing that telestroke improves the delivery of acute stroke care for patients, and is associated with improved post-stroke patient outcomes.”

The findings do suggest that the implementation of telestroke alone is not enough to substantially impact stroke systems of care, Dr. Zachrison added.

To take a closer look at the impact of telestroke, a web-based approach to using video telecommunication to treat stroke patients before they’re admitted to the hospital, the researchers matched 593 U.S. hospitals that had adopted telestroke between 2009 and 2016, but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals, to 593 controls without telestroke, based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership.

Among the matched hospital pairs, 261 (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals.

Changes from the two years before telestroke implementation to the two years following implementation were similar at telestroke and control hospitals, the study found. Mean annual stroke volume at telestroke hospitals decreased from 79.6 to 76.3 patients, and at control hospitals from 78.8 to 75.5 patients.

In a 20% random sample of distances traveled by ambulances, mean distance increased from 14.0 to 14.2 miles for telestroke hospitals, and from 14.0 to 14.6 miles for control hospitals, a nonsignificant difference.

Similarly, the proportion of patients with stroke who transferred to another hospital increased from 5.7% to 6.8% among telestroke hospitals and from 4.8% to 5.8% among control hospitals, also nonsignificant.

“This is an interesting study that looks at an incredibly important topic, telestroke to provide early consultation for patients with acute stroke,” said Dr. Elisabeth B. Marsh, an associate professor of neurology and director of the Bayview Comprehensive Stroke Center at the Johns Hopkins University School of Medicine in Baltmore, who wasn’t involved in the study.

“Initially it may surprise many that differences were not found with respect to inter-hospital transfer rates and hospital volumes between hospitals participating in telestroke initiatives versus those who do not,” Dr. Marsh said in an email. “However, I would caution that while the authors did not find differences in the measures they evaluated, that does not mean that there may not be other differences, for example in length of stay or functional outcome rather than simply mortality, that make telestroke a valuable and effective intervention.”

“In addition, while a strength of this study is the large sample size, there are likely additional confounders impacting the results,” Dr. Marsh said. “Patient groups or health care systems with certain characteristics may preferentially benefit from a telestroke model. This study is an important first step to determine who may derive maximal benefit. “

SOURCE: JAMA Network Open, online September 23, 2021.

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