By Bart Demaerschalk, MD, and Lee Schwamm, MD
A policy statement released last year from the American Heart Association (AHA) recommends that whenever local or on-site acute stroke expertise or resources are insufficient to provide around-the-clock coverage for a health care facility, telestroke systems should be deployed to supplement resources at participating sites.1
Our hope is that this statement will motivate the stroke provider community to continue to address barriers limiting the implementation and expansion of stroke telemedicine, and to increase emergency evaluation and treatment for patients with stroke in rural and neurologically underserved regions.
Almost 800,000 strokes occur annually in the United States; however there are only four neurologists per 100,000 people in this country, largely concentrated in urban areas and academic centers. This contributes to a substantial rural-metropolitan disparity in acute stroke care. Eligible stroke patients presenting to rural community hospitals are nearly 10 times less likely to receive thrombolysis than those presenting to urban primary stroke centers. 2
Vascular neurologist consultations with emergency physicians result in more accurate decision making when performed via telemedicine vs. telephone. The more frequent appropriate decisions, high rates of thrombolysis use, low rates of intracerebral hemorrhage or technical complications, and favorable time requirements all support the efficacy of telemedicine for making stroke treatment decisions. 3
Correct acute stroke treatment decisions were made more often in the telemedicine group versus the telephone-only group (98% vs. 82%). Stroke telemedicine when compared with telephone-only consultations was more sensitive (100% vs. 58%), more specific (98% vs. 92%), had a more favorable positive likelihood ratio (LR: 41 vs. 7) and negative likelihood ratio (LR: 0 vs. 0.5), and had higher predictive values (positive predictive value 94% vs. 76%, and negative predictive value 100% vs. 84%) for the determination of thrombolysis eligibility. 4
In addition, the safety of immediate transfer after remotely supervised IV thrombolysis ("drip and ship") has recently been reported and appears comparable to conventionally administered IV tPA at a tertiary center 5.
The recently completed STRokE DOC Arizona TIME Trial determined that it was feasible to extend the original STRokE DOC trial protocol to a neighboring state and establish an operational single hub, multi-spoke rural hospital telestroke network. Overall, the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise. 6, 7
1 Schwamm LH, et al. Stroke published online May 7, 2009.
2 Miley ML, et al. Telemed J E Health 2009 Sep; 15(7):691-9.
3 Meyer BC, et al. Lancet Neurol 2008; 7: 787–95.
4 Capampangan DJ, et al Neurologist 2009 May; 15(3):163-6.
5 Pervez et al. Stroke 2010 Jan;41(1):e18-24.
6 Demaerschalk et al. Stroke 2010.
7 Demaerschalk et al. Mayo Clin Proc 2009; 84(1):53-64.
Bart Demaerschalk, MD, has served in an editorial capacity for the following publications:
Dr. Demaerschalk has received research support from the following entities: Arizona Department of Health Services, Medting, Calgary Scientific, NIH NINDS, Mitsubishi and AGA.
Lee Schwamm, MD, has received personal compensation from the following entities for consulting, serving on a scientific advisory board, speaking, and other activities: Massachusetts Dept. of Public Health, RTI Health, CoAxia, Lundbeck, Phreesia Quantia MD, CryoCath (now owned by Medtronic) and AHA's get with the guidelines (GWTG) program.
Dr. Schwamm also reviews medical malpractice cases in defense of physicians involved in cases mostly of cerebrovascular diseases.
He has received research support from the following entities: Health Resources and Services Administration (HRSA), National Institutes of Health/ National Institute of Neurological Disorders and Stroke (NIH / NINDS), Department of Health and Human Services/Centers for Disease Control (DHHS/CDC).
Dr. Schwamm serves on the editorial boards of Stroke and Neurocritical Care