Does telestroke participation improve hospitals’ clinical outcomes?

Participating in telemedicine for ischemic stroke care could modestly lower a hospital’s rate of tissue-type plasminogen activator (tPA)-related complications and in-hospital mortality, researchers reported in Circulation: Cardiovascular Quality and Outcomes.

Donglan Zhang, PhD, led an observational study that assessed the efficacy of telestroke—the application of telemedicine to stroke care using two-way technologies—in a network of rural hospitals in Georgia. The REACH (Remote Evaluation for Acute Ischemic Stroke) program, a fixture in the state since 2003, facilitates communication between neurologic specialists and physicians at rural hospitals who may lack the training or specialization to diagnose certain acute cases.

“Effective management of acute ischemic stroke requires minimizing delays in care and timely decision to administer the thrombolytic drug intravenous tPA because there is an average reduction in efficacy of 1.1 percent for every 10-minute delay to treatment,” Zhang and coauthors wrote. “A telestroke program’s effectiveness is dependent on uninterrupted availability of stroke specialists, technology readiness in referral hospitals and the ability to quickly transport patients with stroke to an advanced stroke center.

“Meanwhile, advanced information technology by itself does not necessarily result in optimal care.”

Zhang et al. drew data from the Georgia Coverdell Acute Stroke Registry for their study, which used a difference-in-differences approach to compare a host of clinical outcomes and quality indicators among 25,494 ischemic stroke patients admitted to hospitals within and outside of the REACH network between 2005 and 2016. In total, 27.4 percent of patients were admitted to a hospital within the telestroke network, and 72.6 percent were admitted to a hospital outside of the network.

Among the factors considered by researchers were tPA, tPA-related complications, door-to-needle time (DTN), ambulatory status before stroke, discharge status and destination. Results were adjusted for patients’ age, sex, race, insurance status, stroke severity, medical history and hospital bed size.

The authors found hospitals that participated in the telestroke network saw a 5.9 percent decline in the rate of complications related to tPA, though they didn’t see any significant increase in the rate of tPA use itself. Telestroke participation showed no significant difference in any other clinical outcomes other than a 1.1 percent decrease in hospital mortality among participating practices.

“The relatively small sample size of patients with ischemic stroke in telestroke-participating hospitals, as compared with the sample size of patients in the nonparticipating hospitals, suggests that many patients are still treated in hospitals not covered by telestroke networks,” Zhang and colleagues wrote. “Findings from our study suggest that the telestroke program’s impact on quality improvement is yet to be established and special attention is needed to quality measures like DTN time where telestroke-participating hospitals recorded longer DTN time than those nonparticipant hospitals.”

The authors said although they observed “encouraging signs in secondary outcome measures,” like the modest decrease in inpatient mortality, more research needs to be done before anyone can conclude telestroke participation increases a hospital’s quality of care.