Help from afar: telemedicine vs. telephone advice for stroke

At Tobey Hospital, Southcoast Hospitals Group's 70-bed facility in Wareham, Mass., decisions about treating acute stroke patients were once made mainly by an emergency department physician, with the help of a local radiologist's CT screening. There was, and still is, no neurologist at the ready; the hospital's in-person neurology coverage comprises a specialist who comes in three out of four Tuesdays for inpatient consults.

Four years ago, however, things changed. Tobey joined a telestroke program that connects the facility via audio and video feed with Massachusetts General Hospital and Brigham and Women's Hospital in Boston, 60 miles away. Now a designated stroke center, Tobey has access to top-notch neurologists at all hours of the day and night. The result? Acute stroke patients have gone from receiving tissue plasminogen activator (tPA) once or twice a year to receiving it 10 times in the last 18 months, said Nancy Edwards, MD, medical director of Tobey Hospital's Stroke Program.

“The telemedicine program helps us make better decisions about care for our patients,” Dr. Edwards said. “And the patients and their families love it. They feel they receive the benefit of a ‘Boston’ level of expertise with all the comforts of home.”

Stroke telemedicine has plenty of champions, both from the community hospital (or “spoke”) side and the tertiary stroke center (or “hub”) side. Many see it as an ideal way to treat patients in areas with limited neurology resources, often rural areas. Yet others think the best solution to reaching remote or underserved patients is to simply set up a telephone system for consultation, and skip the expense and hassle of purchasing and maintaining audio-visual equipment.

“If we look at what it takes to have a good stroke outcome when we treat from far away, we know speed, accuracy, cost and liability are factors,” said James Frey, MD, chief of the neurovascular section at Barrow Neurological Institute in Phoenix. “I posit the phone has the lead on all of these.”

Tortoise or hare?

Experts sparred over whether telephone advice or telemedicine is best during a session at February's International Stroke Conference 2009 in San Diego. Taking a tip from the session title, “Telemedicine vs. Telephonic Advice for tPA Administration: The Tortoise or the Hare?”, both used the fable of the two racing animals to argue their points.

Telemedicine may be slower, in that it requires setting up equipment and getting patients and doctors on both ends to the right place, but like the tortoise, it ultimately wins the race because it is more exact, argued Brett Meyer, MD, co-director of the University of California, San Diego Stroke Center, which has a telemedicine program.

“With telemedicine, you can make a visual assessment of the patient; you can see where you are going,” Dr. Meyer said. “In order to win the race, you have to see the finish line.”

Dr. Frey noted, however, that the fable itself misrepresents its main characters: in the real world, the hare always wins.

“A more accurate representation shows the hare as completely on the alert; this is a disciplined, organized animal,” Dr. Frey said. “And people who treat with tPA by telephone are in fact organized and accurate, because we train them to be.”

Telephone consultation doesn't have the multitude of problems that telemedicine has, Dr. Frey added. Those problems include confusion over who gets reimbursed for care, the hub or the spoke hospital; what kind of liability coverage is necessary for either hospital; interstate physician licensing for the hospitals providing the care; equipment costs that can add up to $100,000, plus $4,000 a month for technology support fees; and quality assurance for all the equipment.

“And then there are the internal factors: Everyone has to be organized at all places involved,” Dr. Frey said. “You need tech support; you need training and education for staff.”

Evaluating the evidence

A September 2008 Lancet Neurology article compared telephone consultation and telemedicine to see which led to more accurate decisions about treating acute stroke patients with tPA. Telemedicine won out, with physicians making correct decisions 98% of the time when telemedicine was used, compared with 82% of the time when telephone consultation was used.

“Looking at it another way, nearly one in five times when you pick up the phone, you're at risk of making the wrong decision,” said Dr. Meyer, lead author of the study. “So we may be treating patients we shouldn't be by treating them over the phone, and we may not be treating the patients we should.”

Phone consultation may be more prone to wrong decisions for a couple of reasons, said Dr. Edwards (whose hospital, as a caveat, has not used phone consultation specifically for stroke). One is that there are a number of ischemic stroke mimics which could throw a consulting doctor off, if he or she only hears a list of symptoms but doesn't actually see the patient. These mimics range from hypoglycemia to cerebral trauma.

“Some (mimics) are easy to handle over the phone, like hypoglycemia; you remind the physician to check blood glucose, and treat it if it's low. But others, like reversible cerebral vasoconstrictive syndrome or dementia, could be very difficult to do over the phone,” Dr. Edwards said.

Emergency physicians can also be reluctant to use tPA for liability reasons, and may downplay certain symptoms on the phone out of caution—and emphasize, instead, that a patient appears to be improving, she added. With telemedicine, there is less ambiguity because the consulting physician can actually see the patient and do an exam, she said.

Another problem with telephone consultation, the Lancet Neurology study found, is that it results in more incomplete data being collected about patients. Twelve percent of patients in the telephone group had incomplete data, compared with 3% in the telemedicine group, Dr. Meyer said.

That may be true, said Dr. Frey, but actual outcomes after treatment ended up being the same or better with telephone consultation. The rate of intracerebral hemorrhage was virtually the same—7% for telemedicine vs 8% for telephone. The time to treat was shorter, neurological outcomes were better, and mortality was less for the phone patients (19% for telemedicine vs. 13% for telephone patients), he said.

“Here are the facts: telemedicine was better for decision-making about the accuracy of who gets tPA, but it failed to translate into a clinical or cost benefit. The ones who were treated by phone still, ultimately, did clinically better,” Dr. Frey said. “So the conclusion is that the trial designed by the telemedicine advocates in fact demonstrated that telephone did better than telemedicine in a head-to-head trial.”

Dr. Meyer countered, however, that his study of 222 patients wasn't sufficiently powered to reach conclusions about outcomes, and that the difference in mortality Dr. Frey noted wasn't statistically significant. The p-value for mortality was 0.27.

“We still need a trial dedicated to assessing telemedicine for long-term outcomes,” Dr. Meyer said.

A real-life example

Tobey Hospital's Dr. Edwards said she does see the unique benefits of telephone consultation, such as accessibility, cost and ease of use. However, its other advantages, such as being educational for hospital staff and increasing confidence in patients, can be achieved via telemedicine as well.

Yet telemedicine has its drawbacks, too, she said. For one, it takes extra time per patient, because the specialist repeats much of the exam that the ED doctor already did.

There are also high startup costs, hassles with credentialing physicians, and continuous issues of training and retraining, since health care is a high-turnover field.

“So why do we do it? Because the telemedicine program literally brings the neurologist into my hospital. It feels like (he or she) is right there with you,” Dr. Edwards said.

It's not just about tPA, either, she added. The hub hospital provides a second read on CT images, helps with care plans for patients who aren't transferred out of the spoke hospital and allows for additional treatment of the patients who do need to be transferred. In the latter case, Tobey gets a follow-up report on patients who have been transferred.

“The result is the best care possible from a community hospital,” Dr. Edwards said.