STRok E STRok E DOC DOC

Tel eSt r oke Tel eSt r oke: :

I t t E t i I t t E t i I nst ant Ex per t i se I nst ant Ex per t i se
Neur ol ogi c al Emer genc i es & Neur ol ogi c al Emer genc i es & Neur oc r i t i c al Neur oc r i t i c al Car e Conf er enc e Car e Conf er enc e
New Yor k New Yor k
6/14/12 6/14/12
Br et t C. Meyer MD Br et t C. Meyer MD
UCSD St r oke Cent er UCSD St r oke Cent er
UCSD Stroke Center
Evidence for the Use of Telemedicine in
Stroke Systems of Care: Stroke Systems of Care:
Background:
rt-PA use is a marker for acute stroke management
rt-PA is underused (2-5%)!!!.
Reasons include specialist availability, immediate
access to care, and complex decision- making
Stroke expertise is required. p q
Geographic disparities are immense!
Telemedicine may increase access to expertise, y p ,
especially for remote areas.
Telemedicine might be implemented within a Stroke
Systems of Care Model to address these
deficiencies.
Di sc ussi on: Di sc ussi on:
St r oke Car e St r oke Car e
-- Li mi t at i ons Li mi t at i ons
-- Pot ent i al Sol ut i ons Pot ent i al Sol ut i ons
St r oke Tel emedi c i ne St r oke Tel emedi c i ne
-- Rel i abi l i t y Rel i abi l i t yyy
-- Syst ems & Ef f i c acy Syst ems & Ef f i c acy
Tel eSt r oke Tel eSt r oke
-- STRok E STRok E DOC DOC
-- Tel emedi c i ne Evi denc e Tel emedi c i ne Evi denc e
-- Tel eSt r oke Tel eSt r oke-- I nst ant Ex per t i se I nst ant Ex per t i se
The Pr obl em: Li mi t ed Use The Pr obl em: Li mi t ed Use
Tel emedi c i ne has gai ned Tel emedi c i ne has gai ned Tel emedi c i ne has gai ned Tel emedi c i ne has gai ned
i nt er nat i onal at t ent i on. i nt er nat i onal at t ent i on.
The goal i s t o br i ng st r oke ex per t i se The goal i s t o br i ng st r oke ex per t i se
t o r ur al ar eas. t o r ur al ar eas.
t o ALL ar eas.
Tel emedi c i ne i s Technol ogy + ?. Tel emedi c i ne i s Technol ogy + ?.
Why i snt i s bei ng used mor e? Why i snt i s bei ng used mor e?
Ac ut e St r oke Car e: Ac ut e St r oke Car e:
Detection Detection
Dispatch Dispatch
Delivery Delivery
Door/ Data Door/ Data
Decision/ Drug Decision/ Drug
Chai n of
TPA
Chai n of
Sur vi val
Ac ut e St r oke Car e: Ac ut e St r oke Car e:
Detection
Decision/ Drug Decision/ Drug
Tel e- Tel e-
Medi c i ne
TPA
How It Works
------------------------ ------------------------
Hess DC, Switzer J A. Hess DC, Switzer J A. Neurology Neurology. 2011. Published Ahead of Print. 3/2/11 . 2011. Published Ahead of Print. 3/2/11
TPA TPA-- Ti me i s Br ai n Ti me i s Br ai n
Tel emedi c i ne St udi es: Tel emedi c i ne St udi es:
Fr equent Use: Fr equent Use: Fr equent Use: Fr equent Use:
t el e t el e-- medi c i ne f or st r oke medi c i ne f or st r oke
11
t el e t el e-- pat hol ogy pat hol ogy t el e t el e-- c r i t i c al c ar e c r i t i c al c ar e t el e t el e-- c ar di ol ogy c ar di ol ogy
22
t el e t el e-- der mat ol ogy der mat ol ogy t el e t el e-- r heumat ol ogy r heumat ol ogy t el e t el e-- psychi at r y psychi at r y gy gy gy gy p y y p y y
t el e t el e-- sur ger y sur ger y t el e t el e-- neur osur ger y neur osur ger y t el e t el e-- t r auma t r auma
33
t el e t el e-- educ at i on educ at i on t el e t el e-- c or r ec t i onal c ar e c or r ec t i onal c ar e
M l t i l St di M l t i l St di Mul t i pl e St udi es: Mul t i pl e St udi es:
* * * r el i abi l i t y* * * * * * r el i abi l i t y* * *
wel l est abl i shed pr oof of c onc ept wel l est abl i shed pr oof of c onc ept
i t / t h i i t / t h i var i ous syst ems/ t echni ques var i ous syst ems/ t echni ques
______________ ______________
11
Meyer et al. Neurology. 2005;64:1058 Meyer et al. Neurology. 2005;64:1058- -1060. 1060.
22
Sable et al. Pediatrics. 2002; 109. Sable et al. Pediatrics. 2002; 109.
33
Rogers et al. J . Trauma. 2001; 51: 1037 Rogers et al. J . Trauma. 2001; 51: 1037- -1041. 1041.
Tel emedi c i ne: St r oke Tel emedi c i ne: St r oke
Reliability: Reliability:
--Multiple systems is use. Multiple systems is use.
--Clinical Deficit Scales (NIHSS, CSS) Clinical Deficit Scales (NIHSS, CSS)
K=44 K=44--67% 67%
--Trials of Trials of telestroke telestroke reliability: reliability:
Shafqat Shafqat & Schwamm & Schwamm
11
22
Wang Wang
22
Meyer Meyer
33
Handschu Handschu
44
______________ ______________
11
Shafqat et al. Stroke. 1999;30:2141 Shafqat et al. Stroke. 1999;30:2141- -2145 2145
22
Wang et al. Stroke.2003;34:188e Wang et al. Stroke.2003;34:188e- -191e, 191e,
33
Meyer et al. Stroke. Neurology. 2005;64:1058 Meyer et al. Stroke. Neurology. 2005;64:1058- -1060. 1060.
44
Handschu et al. Stroke. 2003;34:2842 Handschu et al. Stroke. 2003;34:2842- -2846. 2846.
CO CO--DOC DOC (Fanale: Denver CO) (Fanale: Denver CO) US: US:
Tel emedi c i ne: St r oke Tel emedi c i ne: St r oke- - Feasi bi l i t y Feasi bi l i t y
CO CO--DOC DOC (Fanale: Denver, CO) (Fanale: Denver, CO)
Detroit Medical Center Systemwide Stroke Initiative Detroit Medical Center Systemwide Stroke Initiative (Madhavan: Detroit, MI) (Madhavan: Detroit, MI)
University of Maryland Brain Attack Center University of Maryland Brain Attack Center (Stern: Baltimore, MD) (Stern: Baltimore, MD)
Maryland Telemedicine Maryland Telemedicine (LaMonte: Baltimore, MD) (LaMonte: Baltimore, MD)
Methodist Hospital Telestroke Program Methodist Hospital Telestroke Program (Hanson: St. Louis Park, MN) (Hanson: St. Louis Park, MN)
Michigan Stroke Network Michigan Stroke Network (Fessler: Pontiac, MI) (Fessler: Pontiac, MI)
Montana Stroke Initiative Montana Stroke Initiative (Okon: Billings & Great Falls, MT) (Okon: Billings & Great Falls, MT)
US: US:
MUSC Reach Stroke Network MUSC Reach Stroke Network (Adams: Charleston, SC) (Adams: Charleston, SC)
Nevada Telemedicine/ Renown Institute for Neurosciences Nevada Telemedicine/ Renown Institute for Neurosciences (Katz: Reno, NV) (Katz: Reno, NV)
New York State Rural Telemedicine Initiative New York State Rural Telemedicine Initiative (Morley: Cooperstown, Buffalo, Syracuse, NY) (Morley: Cooperstown, Buffalo, Syracuse, NY)
OSF Stroke Network OSF Stroke Network (Wang: Peoria, IL) (Wang: Peoria, IL)
Partners TeleStroke Center Partners TeleStroke Center (Schwamm: Boston, MA) (Schwamm: Boston, MA)
REACH MCG REACH MCG (Hess: Augusta, GA) (Hess: Augusta, GA)
Sacred Heart Regional Stroke Center Sacred Heart Regional Stroke Center (Neill: Pensacola FL) (Neill: Pensacola FL) Sacred Heart Regional Stroke Center Sacred Heart Regional Stroke Center (Neill: Pensacola, FL) (Neill: Pensacola, FL)
STRokE DOC STRokE DOC (Meyer: San Diego, CA) (Meyer: San Diego, CA)
STARR Network STARR Network (Demaerschalk: Scottsdale, AZ) (Demaerschalk: Scottsdale, AZ)
Swedish Medical Center TeleStroke Program Swedish Medical Center TeleStroke Program (Cress: Seattle, WA) (Cress: Seattle, WA)
Texas Telephysicians Texas Telephysicians (Grotta: Houston, TX) (Grotta: Houston, TX)
UCLA UCLA- - Telestroke Telestroke (Ali: Los Angeles, CA) (Ali: Los Angeles, CA)
UCLA UCLA- - TeleCritical Care TeleCritical Care (Vespa: Los Angeles, CA) (Vespa: Los Angeles, CA) ( p g , ) ( p g , )
University Healthcare Telestroke/ Utah Telehealth University Healthcare Telestroke/ Utah Telehealth (Skalabrin: Salt Lake City, UT) (Skalabrin: Salt Lake City, UT)
UPMC Telestroke Network UPMC Telestroke Network (Wechsler: Pittsburgh, PA) (Wechsler: Pittsburgh, PA)
Alberta Provincial Stroke Strategy Telestroke Initiative Alberta Provincial Stroke Strategy Telestroke Initiative (Calgary & Edmonton, AB) (Calgary & Edmonton, AB)
British Columbia Provincial Telestroke Initiative British Columbia Provincial Telestroke Initiative (Vancouver, BC) (Vancouver, BC)
HELIOS NEURONET HELIOS NEURONET (Ickenstein: Germany/ Saxony, Berlin, Turingia, Westfalia) (Ickenstein: Germany/ Saxony, Berlin, Turingia, Westfalia)
O t i T l h lth N t k T l t k P O t i T l h lth N t k T l t k P (T t ON) (T t ON)
Non Non--US: US:
Ontario Telehealth Network Telestroke Program Ontario Telehealth Network Telestroke Program (Toronto, ON) (Toronto, ON)
RUN RUN--FC FC (Moulin: France/ Besancon) (Moulin: France/ Besancon)
SOS SOS--NET/Saxonia NET/Saxonia (Gahn: Germany/ Dresden) (Gahn: Germany/ Dresden)
STENO STENO (Handschu: Germany/ Bavaria) (Handschu: Germany/ Bavaria)
Stroke Angel Stroke Angel (Ziegler: Germany/ North Bavaria) (Ziegler: Germany/ North Bavaria)
Teleneurology Heidelberg Teleneurology Heidelberg (Lichy: Germany/ Heidelberg) (Lichy: Germany/ Heidelberg)
TELESTROKE TELESTROKE--FINLAND FINLAND (Tatlisumak: Finland/ Helsinki) (Tatlisumak: Finland/ Helsinki) TELESTROKE TELESTROKE FINLAND FINLAND (Tatlisumak: Finland/ Helsinki) (Tatlisumak: Finland/ Helsinki)
Telestroke GSTT Telestroke GSTT (Audebert: UK/ London) (Audebert: UK/ London)
TEMPiS TEMPiS (Schenkel: Germany/ Bavaria) (Schenkel: Germany/ Bavaria)
TESS TESS (Schleyer: Germany/ Swabia) (Schleyer: Germany/ Swabia)
TRUST_TPA TRUST_TPA (Amarenco: France/ Paris) (Amarenco: France/ Paris)
UK/ Northern Ireland UK/ Northern Ireland (Patterson: UK/ Northern Ireland) (Patterson: UK/ Northern Ireland)
St r oke Pat i ent : St r oke Pat i ent :
Tel ephone Ver si on: 3am Tel ephone Ver si on: 3am Tel ephone Ver si on: 3am Tel ephone Ver si on: 3am
phone c al l phone c al l
______________ ______________
Frey J L. et al. Neurology. 2005:64;154 Frey J L. et al. Neurology. 2005:64;154--156. 156.
St r oke Pat i ent : St r oke Pat i ent :
46 l d 46 l d 46 year ol d man. 46 year ol d man.
Ac ut e onset : Ac ut e onset :
STROKE STROKE
Hospi t al w i t hout Hospi t al w i t hout Hospi t al w i t hout Hospi t al w i t hout
a neur ol ogi st . a neur ol ogi st .
Can You Hel p? Can You Hel p? Can You Hel p? Can You Hel p?
UCSD St r oke Tel emedi c i ne
STRok E STRok E DOC: Resear c h Col l abor at i on DOC: Resear c h Col l abor at i on
NI H: NI H: NI H: NI H:
NI H f unded Tr i al [ P50] [ NCT00283868] NI H f unded Tr i al [ P50] [ NCT00283868]
Uni er si t Uni er si t Uni ver si t y: Uni ver si t y:
UCSD St r oke Cent er UCSD St r oke Cent er
Cal Cal --(I T) (I T) Cal Cal --(I T) (I T)
I ndust r y: I ndust r y:
Qual c omm, I nc . Qual c omm, I nc .
BF Technol ogi es, I nc . BF Technol ogi es, I nc .
Tec hnol ogy Opt i ons Tec hnol ogy Opt i ons
Numerous Vendors & Carts (and resellers/ partners) Numerous Vendors & Carts (and resellers/ partners)
Differentiated by price support and features Differentiated by price support and features Differentiated by price, support, and features Differentiated by price, support, and features
There is no vendor shortage There is no vendor shortage
There are also software systems There are also software systems
Tel emedi c i ne Vendor s Tel emedi c i ne Vendor s
Videoconferencing vendors are not tele Videoconferencing vendors are not tele--stroke vendors stroke vendors
Oft l ki di l ti / fl ibilit Oft l ki di l ti / fl ibilit Often lacking medical expertise/ flexibility Often lacking medical expertise/ flexibility
Often lacking QoS control for packet loss Often lacking QoS control for packet loss
Often lacking Decision Support tools Often lacking Decision Support tools Often lacking Decision Support tools Often lacking Decision Support tools
STRok E STRok E DOC: Ai m I I DOC: Ai m I I
Pr oc edur es: Make I t Easy!!! Pr oc edur es: Make I t Easy!!!
C d St k C d St k
Pr oc edur es: Make I t Easy!!! Pr oc edur es: Make I t Easy!!!
Code St r oke Code St r oke



Initiate Code Stroke Pioneers:
Call 619-543-6111.
I f O t f C d St k t Pi H it l
STRokE DOC - ED CHECKLIST AIM 2
STRokEDOC HOTLINE
For suspected CODE STROKE symptoms
Inform Operator of Code Stroke at Pioneers Hospital.

Consent Forms:
Obtain written consent for video consultation (forms in workbook)
ALL signature lines and dates MUST be completed (use N/A if appropriate)

Position STRokE DOC Camera:
Place camera at foot of patient bed.
Verify power to unit (wall jack plugged in)
Verify Internet connection (LAN line/ port plugged in)
Call Hotline #: (619) 543 6111
< 3 hours.
e y e e co ec o ( e/ po pugged )

Verify Consent via remote camera:
Remote Consultant to verify consent to consultation

Verify labs have been drawn:
CBC with platelets
Chemistry Panel
Glucose
PT/PTT/INR
U i P T t (if i t )
Acute Stroke
Inform Operator: Code Stroke
Hospital Name
Telephone #
Urine Pregnancy Test (if appropriate)

Diagnostic Tests
EKG
CT scan

Assist remote MD with bedside evaluation.
General examination
Neurologic examination
Stroke scales
Telephone #
Stroke scales
Review lab results
Review head CT images & results
Discussion of recommendations & treatment plan

Document Evaluation:
Document consultation and findings/ recommendations in medical record.


STRok E DOC: STRok E DOC: Ai m I I Ai m I I
Cl i ni c al Tr i al Pr oc edur es: Cl i ni c al Tr i al Pr oc edur es:
Consul t at i on Consul t at i on
Other Telemedicine Benefits!
rt-PA

Non- rt-PA
Medications (ASA/ Heparin)
Hydration Hydration
Full immersion
Exams
MDDisc ssions MD Discussions
Family Discussions
Life-flight Instructions
Di ti A i t Diagnostic Assistance
Research Therapies
234 234
STRok E STRok E DOC: DOC: r t r t - -PA Rat e PA Rat e
Nat i onal r t -PA r at e: 2-3%
STRok E DOC
r t -PA r at e = 25%
Tel emedi c i ne = 28%
Tel ephone = 23% nss
STRok E STRok E DOC: DOC: r t r t - -PA Rat e PA Rat e
rt-PA Telemedicine Rate
STRokE DOC (Meyer):
1
28%
Partners TeleStroke (Schwamm):
2
25%
CO-DOC (Fanale):
3
22% CO DOC (Fanale): 22%
Maryland (LaMonte 2003):
4
24%
STRokE DOC AZ TIME:
5
30% (telemedicine/telephone)
STARR (Demaerschalk):
6
27% STARR (Demaerschalk): 27%
REACH (Hess)
7
15%
Ontario (Waite)
8
31%
Michigan Stroke Network
9
18% Michigan Stroke Network
9
18%
TEMPiS (Audebert)
10
rt-PA rate raised about 10-fold
*Note: True denominators (all acute strokes) may not be known in all cases. *Note: True denominators (all acute strokes) may not be known in all cases.
_______________________________________________________ _______________________________________________________
11
Meyer BC. et al. Lancet Neurology. 2008:7;787 Meyer BC. et al. Lancet Neurology. 2008:7;787- -795. 795.
22
Schwamm LH et al. Schwamm LH et al. Acad AcadEmerg EmergMed. 2004:11;1193 Med. 2004:11;1193- -1197. 1197.
33
Fanale C.(personal communication). Fanale C.(personal communication).
44
LaMonte et al. Stroke. 2003;34:725 LaMonte et al. Stroke. 2003;34:725- -728. 728.
55
Demaerschalk B. Ongoing Clinical Trials Demaerschalk B. Ongoing Clinical Trials
Abstract #3090 at ISC 2009. Abstract #3090 at ISC 2009.
66
Demaerschalk B. (personal communication) Demaerschalk B. (personal communication)
77
Hess DC et al. Stroke. 2005;36:2018 Hess DC et al. Stroke. 2005;36:2018- -2020. 2020.
88
Waite K et al. J Waite K et al. J Telemed TelemedTelecare.2006;12:141 Telecare.2006;12:141--145. 145.
99
www.michiganstrokenetwork.com www.michiganstrokenetwork.com
10 10
Schwab S. et al. Neurology.2007;69:898 Schwab S. et al. Neurology.2007;69:898--903. 903.
STRok E STRok E DOC: Ti me I nt er val s DOC: Ti me I nt er val s
O ( i ) i i ( i ) ( i ) Overall (min) Telemedicine (min) Telephone (min) P
Onset to Door
Onset to Call
Onset to Decision
159.5 215.72 (n=147)
185.5 225.9 (n=216)
244.2 226.03 (n=216)
163.2 195.72 (n=77)
192.8 234.4 (n=108)
258.0 229.88 (n=107)
155.5 237.16 (n=70)
178.1 217.8 (n=107)
230.6 222.42 (n=109)
0.3520
0.4380
0.0670
Stroke Code Times Stroke Code Times
Onset to rt-PA*
Door to MD Eval
Door to Call
Door toConsent
150.7 35.83 (n=55)
7.61 29.28 (n=124)
35.55 51.13 (n=146)
71815167(n=146)
157.2 37.3 (n=30)
8.75 36.48 (n=68)
31.72 42.66 (n=78)
69324323(n=79)
143.0 33.05 (n=25)
6.23 17.11 (n=56)
39.96 59.42 (n=68)
74756034(n=67)
0.1370
0.6130
0.3760
05280 Door to Consent
Door to Neuro Exam
Door to CT Reading
Door to Decision
71.81 51.67 (n=146)
70.09 34.51 (n=142)
84.77 59.8 (n=119)
97.77 54.05 (n=146)
69.32 43.23 (n=79)
75.21 32.80 (n=75)
84.32 47.38 (n=69)
99.79 43.47 (n=77)
74.75 60.34 (n=67)
64.36 35.72 (n=67)
85.4 74.14 (n=50)
95.51 64.09 (n=69)
0.5280
0.0340
0.6720
0.1980
Call to Consent
Call to Neuro Exam
Call to Decision
Consent to Decision
Consent to rt PA**
33.7 26.38 (n=214)
36.74 32.71 (n=216)
59.98 31.84 (n=216)
27.45 21.17 (n=214)
48 35 19 56 (n=54)
33.55 25.45 (n=109)
43.4 29.6 (n=109)
64.71 29.06 (n=108)
32.04 17.34 (n=107)
51 23 17 78 (n=30)
33.85 27.44 (n=105)
29.95 34.44 (n=107)
55.24 33.88 (n=108)
22.86 23.61 (n=107)
44 75 21 42 (n=24)
0.8940
<0.001
0.0250
<0.001
0 1630
Patient treatment: Patient treatment: 2.5 hours 2.5 hours
Consent d ration Consent d ration 30 min tes 30 min tes
Consent to rt-PA**
Decision to rt-PA***
48.35 19.56 (n=54)
12.5 9.55 (n=54)
51.23 17.78 (n=30)
10.03 9.75 (n=30)
44.75 21.42 (n=24)
15.58 8.51 (n=24)
0.1630
0.0190
Consent duration: Consent duration: 30 minutes 30 minutes
Consultation time: Consultation time: 30 minutes (32 30 minutes (32 vs vs 22) 22)
Giving Giving rt rt--PA: PA: More rapid in Telemedicine arm More rapid in Telemedicine arm
STRok E STRok E DOC: Out c omes DOC: Out c omes
OUTCOMES Analyses
SDAC
Telemedicine Telephone Odds Ratio
(95% CI)
P value
Overall
Level 2b Decision
(Primary)
n=110
98%
n=111
82% 10.9 (2.7 - 44.6) 0.0009 relr
(<0.0001 cmh)
Level 1 (SDAC)
Level 2a (MM)
Level 3a (MM)
97%
96%
97%
83%
93%
93%
7.2 (2.1 - 24.6)
2.0 (0.6 - 6.9)
2.7(0.7- 10.5)
0.0009 cmh
0.4037 cmh
0.2383cmh
( )
Level 3b (SDAC)
+rt-PA Subgroup
97%
97%
93%
83%
2.7 (0.7 10.5)
7.2 (2.1 - 24.6)
0.2383 cmh
0.0008 cmh
Primary Outcome: Primary Outcome: Correct Decision Correct Decision--Making Making
98% vs 82% 98% vs 82%
Level 2b (SDAC)
97% 76% 7.4 (1.03 - 53.2) 0.0466 cmh
98% vs. 82% 98% vs. 82%
____________________________________________ ____________________________________________
11
Meyer BC. et al. Lancet Neurology. 2008:7;787 Meyer BC. et al. Lancet Neurology. 2008:7;787- -795. 795.
STRok E STRok E DOC: Pat i ent Out c omes DOC: Pat i ent Out c omes
Telemedicine Telephone Odds Ratio
(95% CI)
P value
Overall n=110 n=111 Overall
Overall Post Consult ICH
90d BI (95-100)
90d mRS (Dichotomized 0-1)
O ll M t lit
n 110
7%
43%
34%
19%
n 111
8%
54%
47%
13%
0.8 (0.1 - 6.3)
0.6 (0.4 - 1.1)
0.6 (0.3 - 1.1)
1 6 (0 8 3 4)
1.0000
*
0.1268
*
0.0898
*
0 2690* Overall Mortality
+rt-PA Subgroup
Post rt-PA ICH
90d BI (95 100)
19%
n=31
7%
33%
13%
n=25
8%
48%
1.6 (0.8 - 3.4)
0.8 (0.1 - 6.3)
0 5 (0 2 1 6)
0.2690*
1.0000
*
0 2865
*
90d BI (95-100)
90d mRS (Dichotomized 0-1)
Subgroup Mortality
Adjusted for Baseline NIHSS
33%
30%
39%
48%
32%
12%
0.5 (0.2 - 1.6)
0.9 (0.3 - 2.9)
4.6 (1.1 - 19)
3.4 (0.6 - 19)
0.2865
1.0000
*
0.0340
*
0.1681 lr
ICH: ICH: No difference No difference
Functional Outcome: Functional Outcome: No difference No difference
Overall Mortality: Overall Mortality: No difference No difference (19% vs. 13% at 90 days) (19% vs. 13% at 90 days)
Subgroup Mortality: Subgroup Mortality: No difference after adjusting for NIHSS (=16) No difference after adjusting for NIHSS (=16) g p y g p y j g ( ) j g ( )
_______________________________________________________ _______________________________________________________
Meyer BC. et al. Lancet Neurology. 2008:7;787 Meyer BC. et al. Lancet Neurology. 2008:7;787- -795. 795.
*Note: Can not assess patient outcomes using small subgroups.
STRok E STRok E DOC: DOC: NI H Cl i ni c al Tr i al NI H Cl i ni c al Tr i al
Cor r ec t t r eat ment dec i si ons:
t el emedi c i ne 98% vs 82% t el ephone (p=00009) t el emedi c i ne 98% vs 82% t el ephone (p=00009)
t -PA:
t el emedi c i ne 28% vs 23% t el ephone (p=043) p
No di f f er enc es i n Out c omes or Mor t al i t y
Meyer BC et al. Lancet Neurol. 2008;7:787 Meyer BC et al. Lancet Neurol. 2008;7:787--795. 795.
STRok E STRok E DOC: Fur t her Anal ysi s DOC: Fur t her Anal ysi s
Sensi t i vi t y = 100% vs. 58%
Spec i f i c i t y = 98%
Li kel i hood Rat i o= 41
Number Needed t o Assess = 6
Capampangan DJ et al. The Neurologist. 2009;15:163 Capampangan DJ et al. The Neurologist. 2009;15:163- -166. 166.
OUTCOMES Analyses Telemedicine Telephone Odds Ratio P value OU CO S a yses
SDAC
e e ed c e e ep o e Odds at o
(95% CI)
a ue
Overall
Level 2b Decision
n=137
96%
n=138
83% 4.2 (1.7 10.5) 0.002 cmh
(Primary)
Level 1 (SDAC)
Level 2a (MM)
96%
96%
84%
94%
4.1 (1.6 10.4)
1 3 (0 5 3 9)
0.003 cmh
0 83 h
Level 2a (MM)
Level 3a (MM)
Level 3b (SDAC)
96%
96%
95%
94%
94%
86%
1.3 (0.5 3.9)
1.6 (0.5 5.0)
3.0 (1.3 7.3)
0.83 cmh
0.61 cmh
0.02 cmh
Primary Outcome: Correct Decision-Making
96% vs. 83%
Correctness of Decision-Making in acute stroke again favors
telemedicine over telephone (96%) in a larger data set.
Telestroke rt-PA Recommendations
TEMPiS: (Efficacy-Outcomes)
Patients: Patients:
170 rt 170 rt PA patients in telestroke hospitals PA patients in telestroke hospitals 170 rt 170 rt--PA patients in telestroke hospitals PA patients in telestroke hospitals
132 rt 132 rt--PA patients in stroke center hospitals. PA patients in stroke center hospitals.
Mortality Mortality
6 th t lit (14 2% 13% 0 45) 6 th t lit (14 2% 13% 0 45) 6 month mortality (14.2% vs. 13%; p=0.45). 6 month mortality (14.2% vs. 13%; p=0.45).
Good functional outcome: Good functional outcome:
6 month mRS 6 month mRS (39.5% vs. 30.9%; p=0.10) (39.5% vs. 30.9%; p=0.10)
6 month BI 6 month BI (47.1% vs. 44.8%; p=0.44) (47.1% vs. 44.8%; p=0.44)
Limitations: Limitations:
Cluster Cluster--control vs. Randomized control vs. Randomized
Unblinded endpoint Unblinded endpoint
Exclusion of NIHSS > 20 Exclusion of NIHSS > 20
Results reflect telestroke evaluation + stroke team training Results reflect telestroke evaluation + stroke team training
______________ ______________
Schwab S. et. al. Schwab S. et. al. Neurology. Neurology. 2007;69:898 2007;69:898--903. 903.
Telestroke rt-PA Recommendations
Finnish Telestroke: (Efficacy-Outcomes) (published after evidence paper)
Patients:
106 telestroke consultations 61 rt-PA patients 106 telestroke consultations, 61 rt-PA patients.
ICH
6.7%
Mortality
3 month mortality (11.5%).
Good functional outcome: Good functional outcome:
3 month mRS (0-2) (49.1% vs. 58.1%; p=0.214)
3 month mRS (0-1) (29.4% vs. 36.8%; p=0.289)
Li it ti Limitations:
Non-randomized 2 year experience
Conclusions: Conclusions:
Feasible, High rt-PA rate, Safe, Appropriate Outcomes
______________
Sairanen T et al. Neurology. 2011. Published ahead of print 3/2/11
Tel emedi c i ne: Level s of Evi denc e Tel emedi c i ne: Level s of Evi denc e
Schwamm et al. Stroke. Schwamm et al. Stroke.
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Tel emedi c i ne: Level s of Evi denc e Tel emedi c i ne: Level s of Evi denc e
Summary of Recommendations
(Class I) (Class I)
1. Telemedicine for non-acute NIHSS exam (I,A)
2. for acute NIHSS exam when bedside not available (I,A)
3. for rt-PA decisions when bedside not available (I,B)
4. can help complete stroke units (I,B)
5. OT/PT/Sp when bedside impractical, if validated and structured (I,B)
6. Teleradiology for acute CT (I,A)
7. for CT rt-PA exclusions. (I,A)
8. for supporting rt-PA decisions (I, B)
9 Telephone for functional disability when bedside impractical if validated and 9. Telephone for functional disability when bedside impractical, if validated and
structured (I,B)
(Class II)
1. Telemedicine for general neurological examination (IIa, B).
2 ith d ti & t i i i f l t i t PA (II B) 2. with education & training is useful to increase rt-PA (IIa, B).
3. OT/PT is reasonable when bedside is impractical (IIa, B).
4. Telephone without teleradiology is not well established (IIb, C).
5. (prehospital) can facilitate enrollment into protective trials (IIa, B).
Schwamm et al. Stroke. Schwamm et al. Stroke.
Online Ahead of Print 5/09 Online Ahead of Print 5/09