Published: Aug 26, 2014
A telestroke program in rural Bavaria cut door-to-needle times by half and the lag between symptom onset and first treatment by 20%, researchers said.
In 2003, the first year in which the TeleMedical Project for Integrative Stroke Care, or TEMPiS, was implemented, median onset-to-treatment and door-to-needle times were 150 minutes (interquartile range 127-163) and 80 minutes (IQR 68-101), respectively, according to Peter Müller-Barna, MD, of the Städtisches Klinikum München GmbH in Munich, and colleagues.
By 2012, the corresponding values had fallen to 120 minutes (IQR 90-160) and 40 minutes (IQR 29-59), respectively (both P0.001), the researchers reported online in Stroke.
During the same interval, the proportion of patients receiving thrombolytic therapy rose from 2.6% to 15.5%.
“The main findings of 10-year experience of TEMPiS showed that this type of telemedical stroke unit network is sustaining, offers state-of-the-art acute stroke care by increasing access to stroke units and improving thrombolysis service, and is associated with long-term improvement in terms of quality indicators of acute hospital care,” Müller-Barna and colleagues wrote.
Telemedicine — the use of modern teleconferencing technology to evaluate patients remotely and to recommend treatment strategies — has increasingly been adopted in developed countries as a way to bring specialist care to rural areas where it is otherwise scarce or unavailable.
In the stroke setting, it involves putting stroke neurologists located mainly in urban tertiary care centers on call to evaluate patients brought into community hospitals in distant towns.
From 2003 to 2012, a total of almost 55,000 patients with stroke or transient ischemic attack (TIA) were evaluated in Bavarian hospitals participating in TEMPiS. Numbers rose steadily each year, from 4,109 in 2003 to 7,207 in 2012.
The proportion evaluated via telemedicine also rose: from just under half initially to 63% in the final year.
Nearly every gross measure of stroke care quality also improved during the study period. As noted above, median times from symptom onset to treatment and median door-to-needle time both fell, and the proportion of patients receiving thrombolytic therapy rose.
In addition, among patients receiving thrombolytic therapy, the proportion getting it within the first hour after admission increased — from 26% in 2003 to 80% in 2012 (P0.001).
And, 7-day in-hospital mortality in TEMPiS stroke patients declined from 5.0% to 3.1% during the study period (P not reported).
Unchanged were the median time from symptom onset to admission, and 7-day mortality in patients receiving thrombolytic therapy — neither of which would likely be affected by a telestroke program.
Müller-Barna and colleagues noted that the 80% of thrombolysis patients receiving it within an hour of admission was well in excess of the American Stroke Association’s target of 50%.
On the downside, the researchers indicated that costs associated with TEMPiS were “substantial” and that these need to be covered for such programs to work.
They suggested that newer technologies hold some promise for reducing these costs. For example, equipping the “teleconsultants” with mobile devices such as tablets or laptop computers, rather than requiring them to use fixed workstations, could reduce the number of consultations needed to make such programs cost-effective.
Limitations to the study include its restriction to certain regions in Bavaria, where the population density (127 per square kilometer) and hence stroke volumes were higher than many rural areas elsewhere. Also, the study relied on administrative records that could contain errors and omissions, and it lacked a control group.
The study was funded by German state and federal government agencies.
Some authors reported relationships with Boehringer Ingelheim, Lundbeck, Pfizer, Bristol-Myers Squibb, Takeda, Sanofi, Roche, and Bayer Vital.
From the American Heart Association:
Primary source: Stroke
Source reference: Muller-Barna P, et al “TeleStroke units serving as a model of care in rural areas: 10-Year Experience of the TeleMedical Project for Integrative Stroke Care” Stroke 2014; DOI: 10.1161/STROKEAHA.114.006141.
John Gever
Managing Editor
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