Tackling tPA and stroke outcomes through telemedicine

Where: 13 “spoke” hospitals across the U.S. without on-site stroke experts.

The issue: Increasing the use of recombinant tissue plasminogen activator (tPA) to treat acute ischemic stroke.

Background

Research and practice have established that tPA, used promptly and appropriately, can improve outcomes for acute ischemic stroke patients. “Frustratingly, even though we have this treatment, less than 5% of stroke patients receive it,” said Jeff Wagner, MD, a neurologist with Blue Sky Neurology in Denver. “I really feel strongly that when there's a stroke expert available during the consultation, that should result in improved ability to deliver treatment in time.”

To confirm this hypothesis, he and colleagues recently conducted an analysis of a telemedicine stroke network. Dr. Wagner presented the results during a plenary session at the American Academy of Neurology's (AAN) annual meeting, held in Philadelphia in April.

How it works

Between 2006 and 2013, the 13 hospitals the researchers studied installed InTouch telemedicine technology, which allowed clinicians to rapidly consult remote stroke experts via 2-way video to decide on appropriate treatment of acute ischemic stroke patients. The participating hospitals were a diverse group. “Most of the hospitals were in the Northeast, but they were spread across the country. Like many spoke hospitals, most were not urban. Several were teaching, and about half of the hospitals were small, defined as under 200 beds,” said Dr. Wagner.

Results

Comparing the hospitals' use of tPA in the year before and the year after implementation of the program revealed significant differences. “There was a dramatic increase in IV tPA delivery after telemedicine as compared to before,” said Dr. Wagner. Specifically, 7.33% of discharged ischemic stroke patients had received tPA under telemedicine compared to 4.53% before (P<0.0001). The change was particularly significant in the under-200-bed hospitals, whose tPA use went from 1.07% to 7.29%. “That is fairly striking,” Dr. Wagner said.

Challenges

However, the 3 smallest hospitals in the project saw little or no improvement in their tPA rates. “My theory is that the very smallest hospitals often have the largest areas of geography. Having telemedicine there may not actually improve your ability to deliver treatment as much, because it's more of an issue of patients getting there on time,” said Dr. Wagner.

One large hospital participating in the program also failed to improve its rates, which Dr. Wagner attributes to lack of widespread buy-in. “There's a huge intangible system that's required to all be working well in order for telemedicine to work ... from the EMS personnel calling stroke alerts in advance, to the ER doctors who have to activate the system. If you don't use the camera, you can't benefit from it,” he said.

Next steps

In concluding his presentation, Dr. Wagner called for further research to investigate why stroke telemedicine seems to work for some hospitals but not others.

Lee Schwamm, MD, who was invited to discuss Dr. Wagner's findings during the AAN plenary session, had additional thoughts. “I think there's a full cycle of stroke care that's ripe for disruption. We don't have to just stop here at the triage decision,” said Dr. Schwamm, who is executive vice chairman of neurology at Massachusetts General Hospital and a professor of neurology at Harvard Medical School in Boston. He called for improvements in care during inpatient stays for stroke, transfers to skilled nursing facilities or home, and outpatient care after discharge.

To improve care for those who've been discharged, his hospital is conducting teleneurology visits with patients in their homes. “We've also expanded and are now implementing pilots in cardiology, psychiatry, and patients in rehabilitation who need frequent evaluations by the burn surgeons,” said Dr. Schwamm. Telemedicine could also allow critical care physicians to keep an eye on patients from home and distant family members to visit a patient in the hospital through their own computers, he added.

“We've seen the benefit in acute stroke care, and now we need future research to demonstrate its benefit in other scenarios in neurologic illness,” Dr. Schwamm said.

Words of wisdom

Although he noted that strong evidence now proves both the benefits and the cost-effectiveness of stroke telemedicine, Dr. Schwamm did caution against attributing all increases in tPA use in the Denver study by Dr. Wagner to telemedicine, as other forces have simultaneously pushed hospitals to improve their practices.

“I would remind all of us about the strong secular trends. Data from the Get with the Guidelines program demonstrates a very rapid rise in the percentage of eligible patients treated with tPA over the past decade,” he said.