Stroke Telemedicine Can Expand Access to Emergency Care of Stroke

Alice Goodman

January 22, 2009

January 22, 2009 — Telemedicine techniques adapted to the emergency care of stroke (ie, telestroke medicine) can address the shortage of stroke expertise and the underuse of effective stroke therapies such as tissue plasminogen activator (tPA), according to a review in the January issue of Mayo Clinic Proceedings.

Telestroke refers to the live audiovisual exchange of medical information from one site to another using electronic communication, allowing for a consultation with a vascular neurologist on individual patients and for monitoring of those patients. Telestroke medicine is particularly suited for areas in which there are shortages of stroke experts and advances in technology, write Bart M. Demaerschalk, MD, at the Mayo Clinic Hospital in Phoenix, Arizona, and colleagues.

The article explores steps in designing a telestroke network and the technology components needed in a telemedicine system, as well as the types of members needed for a telestroke team and characteristics of a "hub and spoke" model for hospitals involved in this system. Emergency medicine physicians, who are often reluctant to use tPA because of perceived risks, would be receptive to joining a telestroke network and treating acute stroke patients with thrombolysis if a telemedicine consultation with a vascular neurologist were possible, according to the authors.

The authors also describe a model telestroke consultation, relying on an algorithm to develop a standard of care. Ideally, both the spoke and hub centers should use the same algorithm to create continuity of care throughout a stroke evaluation, the researchers say.

Obstacles to creating a telestroke system include medicolegal, economic, and market issues. The Stroke Telemedicine for Arizona Rural Residents (STARR) telemedicine program had to overcome all of these issues to develop an efficient functional system. At present, STARR is a 1-hub, 2-spoke system, but plans are in place to add 7 more spoke hospitals soon. The STARR experience showed that about 30% of all acute stroke patients who received a full consultation were determined to be eligible for thrombolysis. The use of thrombolysis in eligible patients increased at participating hospitals 10- to 20-fold during the first 6 months of the program.

The review also discusses future opportunities for telemedicine practice, research, and education, and future opportunities for telestroke practice in particular.

The authors point out that despite having the potential to improve access to care for acute stroke, telestroke practice is currently threatened by unresolved legal, economic, and market factors. "Telestroke practitioners and investigators should focus attention on analyzing and solving the business issues of the practice to allow further advances in the telestroke field and longevity of telestroke practice," they write.

In a related editorial, James F. Meschia, MD, from the Department of Neurology, Mayo Clinic, Jacksonville, Florida, writes that although telemedicine has been shown to reduce the time to administration of tPA in stroke patients, "investigators did not demonstrate that telemedicine improved hard end points, such as case fatality rate, intracranial hemorrhage rate, or functional outcomes. More research is needed to address whether telemedicine can improve these hard end points."

In addition, Dr. Meschia points out that tPA administration is only the beginning of comprehensive care of the stroke patient; postthrombolytic care, rehabilitation, and secondary prevention may also benefit from telestroke practice.

This study was funded by an Arizona Department of Health Services research grant, a Mayo Clinic research grant, the STRokE DOC Arizona—he Initial Mayo Experience (TIME) trial, and the STARR Registry.

Mayo Clinic Proc. 2009;84:53–64.

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