Telestroke Capacity Linked to Increased Odds of Reperfusion Treatment, Lower Mortality

March 8, 2021
Marco Meglio
Marco Meglio

Marco Meglio, Associate Editor for NeurologyLive, has been with the team since October 2019. Follow him on Twitter @marcomeglio1 or email him at mmeglio@neurologylive.com

Increases in reperfusion treatment were the largest in lowest-volume hospitals, among rural residents, and among patients aged 85 years and older.

Recently published data in JAMA Neurology demonstrated that the use of reperfusion treatment and increased stroke outcomes in patients with ischemic stroke are greater in hospital settings with telestroke capacity.1

Lead author Andrew Wilcock, PhD, assistant professor, University of Vermont Lerner College of Medicine, and colleagues sampled 153,272 patients treated for stroke and found that those who received care at hospitals with telestroke capacity had higher rates of reperfusion treatment (6.8%) than those cared for at control hospitals (6.0%; difference, 0.78 percentage points [95% CI, 0.54-1.03]; P <.001).

The researchers also found that telestroke capacity at such hospitals also lent itself to lower 30-day mortality rates (13.1 vs 13.6%; difference, 0.50 percentage points [95% CI, 0.17-0.83]; P = .003) for these patients than those without.

"Across more than 600 hospitals in the US, we found that telestroke capacity was associated with 15% relative increase in receiving reperfusion treatment (thrombolysis with alteplase or thrombectomy) and reduced short-term mortality,” Wilcock et al wrote.

READ MORE: Intensive Motor Arm Therapy Improves mRS Scores in Poststroke Patients

Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge were all the main outcomes and measures.

The risk ratios (RR) for postadmission mortality were 0.95 (95% CI, 0.92-0.99; P = .02) at 7 days, 0.96 (95% CI, 0.94-0.99; P = .003) at 30 days, 0.98 (95% CI, 0.96-1.00; P = .04) at 90 days, and 0.98 (95% CI, 0.97-1.00; P = .09) at 180 days.

Between telestroke and control patients, Wilcock and colleagues did not observe any significant differences on outcomes such as returns to hospital, spending, and living in the community.

Patients who were 85 years and older (RR, 1.18; 95% CI, 1.09-1.27), rural patients (RR, 1.24; 95% CI, 1.17-1.32), admissions that occurred after 2015 (RR, 1.17; 95% CI, 1.11-1.23) and hospitals treating fewer than 2 strokes per month (RR, 1.30; 95% CI, 1.19-1.43) all represented the largest RRs for reperfusion treatment. There were no substantive differences in 30-day mortality from admission across these characteristics.

The analysis included data from stroke episode identified from January 1, 2008 through June 30, 2017; however, when limiting the analysis to telestroke hospitals that had at least 3 years of data following telestroke adoption, reperfusion treatment increased in each of the 3 years after adoption. “Our findings are consistent with prior research that find an association between telestroke capacity and increased reperfusion treatment, although the increases we observed are more modest,” Wilcock and colleagues wrote.

The research into using telemedicine in the stroke area has increasingly grown over the past decade as its benefits continue to be found. Mobile stroke units (MSUs) have been shown to have a significant impact on global function following a stroke when implemented properly.2

A study evaluating German MSUs called STEMOs (Stroke-Einsatz-Mobile) was published in 2020 and included 1543 patients, 749 of which received care from an MSU and 794 who received care from conventional ambulance. Upon analysis, patients with MSU dispatched had lower median modified Rankin Scale (mRS) scores at month 3 (3; interquartile range [IQR], 0-3) than their counterparts without an MSU dispatched (2; IQR, 0-3; odds ratio [OR], 0.71 [95% CI, 0.58-0.86]; P <.001).

Furthermore, patients who had a mobile stroke unit dispatched had lower 3-month coprimary disability score. In comparison, more patients who had no to moderate disability in the mobile stroke unit group (80.3% vs 78%) while fewer patients had severe disability or died (7.1% vs 8.8%). Investigator noted this translated to 27% lower odds of a worse functional outcome when a mobile stroke unit was dispatched (OR, 0.73 [95% CI, 0.54-0.99]; P = .04).

REFERENCES
1. Wilcock AD, Schwamm LH, Zubizarreta JR, et al. Reperfusion treatment and stroke outcomes in hospitals with telestroke capacity. JAMA Neurol. Published online March 1, 2021. doi: 10.1001/jamaneurol.2021.0023
2. Ebinger M, Siegerink B, Kunz A, et al. Association between dispatch of mobile stroke units and functional outcomes among patients with acute ischemic stroke in Berlin. JAMA. Published online February 2, 2021. doi: 10.1001/jama.2020.26345