Wake Forest Baptist tracks as a surrogate measurement whether patients are discharged to home, rehabilitation, or skilled nursing – and 79% are discharged to home or rehab, Dr. Tegeler said.
A few programs are collecting data on 90-day outcomes, an important measurement in clinical trials. For now, though, outcomes are mainly being analyzed with an aim to improve treatment protocols.
Although several studies have demonstrated that outcomes in the "drip and ship" model are comparable with those of patients admitted and treated at dedicated stroke centers, reducing average door-to-needle times and deciding who benefits from "drip and ship" versus "drip and keep" remain key areas of interest.
At the International Stroke Conference in February, neurologist Dr. Shadi Yaghi presented research on a cohort of 562 patients in the Arkansas SAVES program, a telestroke network that links 22 hospitals to stroke specialists at the University of Arkansas Medical Sciences Center in Little Rock. Patients with a worse outcome at 90 days were more likely to have received postthrombolysis care at a spoke hospital (odds ratio, 15.63; P = .019; 95% CI 1.56-166.67), Dr. Yaghi and his colleagues found (Stroke 2012;43:A2885).
"Our study showed that patients with moderate to severe strokes had better outcomes when transferred to a primary stroke center, likely due to more available resources and treatment options, such as neurointerventional treatment and neurocritical care treatment. Those with mild symptoms did not benefit from the transfer," Dr. Yaghi said in an e-mail interview.
Beyond TPA
In Europe and, in particular, Germany, telestroke has developed along a different course, with an emphasis on building multidisciplinary telestroke units in network hospitals.
Instead of concentrating solely on identifying candidates for TPA, network hospitals have teams of nurses, physiotherapists, occupational therapists, speech and language therapists, and physicians trained through seminars held at stroke centers and grand rounds in the affiliated hospitals. Workup of stroke patients is standardized, and treatment includes TPA for qualified patients under a drip-and-keep model.
Neurologist Dr. Peter Müller-Barna of Klinikum Harlaching, Stadtisches Klinikum in Munich, who is project coordinator of the TEMPiS (Telemedic Pilot Project for Integrative Stroke Care) stroke network in Bavaria, said in an interview that dedicated stroke units have proven "very efficient in reducing mortality and dependency in all stroke patients, with a number needed to treat (NNT) of about 5. In comparison to this, intravenous TPA is less effective; the NNT is about 10. Taken together, building up telestroke units is more expensive, but also by far more effective."
The TEMPiS network is one of the most intensively studied telestroke projects in terms of short- and long-term outcomes (Lancet Neurol. 2006;5:742-8; Neurology 2007;69:898-903). Recently, Dr. Müller-Barna and colleagues showed quality of care in TEMPiS network hospitals to be comparable with that seen at conventional stroke units with neurologists (Stroke 2012;43:A2820).
"In my eyes, the main obstacle for not establishing more telestroke programs in the U.S. is the lack of evidence for the telethrombolysis network approach in terms of improved clinical outcome, in contrast to the integrative stroke network approach with its telestroke units," Dr. Müller-Barna said.
Dr. Schwamm, who has collaborated with Dr. Müller-Barna’s group for research, said that much of the difference in the European and American telestroke models can be attributed to the differences in health care systems overall, with European systems better set up to invest in telestroke networks, keep patients in hospitals, and track long-term outcomes.
"In the U.S. the primary driver is the need to provide acute neurological assessment and make sure TPA-eligible patients have a chance to be treated," Dr. Schwamm said. "But telestroke still has lots of collateral benefits. It’s not only drip and keep and drip and ship but evaluate and triage. There’s a lot of that that goes on in telestroke networks even though that’s not the primary driver."
Courtesy Wake Forest Baptist Medical Center
Dr. Charles H. Tegeler
Dr. Tegeler said that the Wake Forest Baptist program is increasingly looking at telestroke consultations as a pathway to other types of interventions.
"For patients who may have missed the window for TPA, telestroke can help facilitate consideration of eligibility for interventional or intraarterial procedures – there’s a whole host of things you could do with the right patients with the right lesions after the 4.5-hour window."
Dr. Tegeler and colleagues at Wake Forest Baptist have successfully pilot tested the use of telestroke technology for postdischarge follow-up visits, allowing patients who were transferred to the medical center for stroke treatment to be followed up, via videoconferencing, at spoke hospitals closer to their homes.