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Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

ABSTRACT: BACKGROUND:The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas. METHODS:Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. RESULTS:The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ?3 hr (OR 2.15; 95% CI 1.37-3.40; I2 = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I2 = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I2 = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I2 = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I2 = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences. CONCLUSION:Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.

SUBMITTER: Lazarus G

PROVIDER: S-EPMC7559631 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

Lazarus Gilbert G Permana Affan Priyambodo AP Nugroho Setyo Widi SW Audrey Jessica J Wijaya Davin Nathan DN Widyahening Indah Suci IS

Brain and behavior 20200818 10

<h4>Background</h4>The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas.<h4>Methods</h4>Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect ...[more]

PMID: 32812380

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Project description:BackgroundEfficacy of telemedicine for stroke was first established by the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trials in California and Arizona. Following these randomized controlled trials, the Stroke Telemedicine for Arizona Rural Residents (STARR) network was the first telestroke network to be established in Arizona. It consisted of a 7 spoke 1 hub telestroke system, and it was designed to serve rural, remote, or neurologically underserved communities.ObjectiveThe objective of STARR was to establish a multicenter state-wide telestroke research network to determine the feasibility of prospective collection, recording, and regularly analysis of telestroke patient consultations and care data for the purposes of establishing quality measures, improvement, and benchmarking against other national and international telestroke programs.MethodsThe STARR trial was open to enrollment for 29 months from 2008 to 2011. Mayo Clinic Hospital, Phoenix, Arizona served as the hub primary stroke center and its vascular neurologists provided emergency telestroke consultations to seven participating rural, remote, or underserved spoke community hospitals in Arizona. Eligibility criteria for activation of a telestroke alert and study enrollment were established. Consecutive patients exhibiting symptoms and signs of acute stroke within a 12 h window were enrolled, assessed, and treated by telemedicine. The state government sponsor, Arizona Department of Health Services' research grant covered the cost of acquisition, maintenance, and service of the selected telemedicine equipment as well as the professional telestroke services provided. The study deployed multiple telemedicine video cart systems, picture archive and communications systems software, and call management solutions. The STARR protocol was reviewed and approved by Mayo Clinic IRB, which served as the central IRB of record for all the participating hospitals, and the trial was registered at ClinicalTrials.gov.ResultsThe telestroke hotline was activated 537 times, and ultimately 443 subjects met criteria and consented to participate. The STARR successfully established a multicenter state-wide telestroke research network. The STARR developed a feasible and pragmatic approach to the prospective collection, storage, and analysis of telestroke patient consultations and care data for the purposes of establishing quality measures and tracking improvement. STARR benchmarked well against other national and international telestroke programs. STARR helped set the foundation for multiple regional and state telestroke networks and ultimately evolved into a national telestroke network.ConclusionsMultiple small and rurally located community hospitals and health systems can successfully collaborate with a more centrally located larger hospital center through telemedicine technologies to develop a coordinated approach to the assessment, diagnosis, and emergency treatment of patients manifesting symptoms and signs of an acute stroke syndrome. This model may serve well the needs of patients presenting with other time-sensitive medical emergencies.Clinical Trial Registration number: NCT00829361.

Project description:Background and purposeTelestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke; however, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration.MethodsPatients who received a telestroke consultation were eligible for a phone interview 2 weeks later, including questions about technology quality, telepresence, and telestroke provider communication. Satisfaction scores ranged from 1 to 7 (higher=more satisfied) and for analyses were dichotomized as 6 to 7 indicating high satisfaction versus <6. Patient variables including stroke severity (measured by the National Institutes of Health Stroke Scale) were obtained from study records. Generalized estimating equation models were used to determine what factors were associated with patient satisfaction.ResultsOver 18 months, 186 interviews were completed, and 142 (76%) reported high satisfaction with telestroke. Patients with more severe stroke were less likely to recall the consultation. Factors significantly associated with patient satisfaction were higher ratings of the technology (P<0.0001), telepresence (P<0.0001), provider communication ratings (P<0.0001), and overall Veterans Affairs satisfaction (P=0.02). In the multivariate model, telepresence (odds ratio, 3.10 [95% CI, 1.81-5.31]) and provider ratings (odds ratio, 2.37 [95% CI, 1.20-4.68]) were independently associated with satisfaction. Veterans who were satisfied were more likely to recommend the technology (P<0.0001).ConclusionsProvider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with the telestroke consultation. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence could improve patient experience with telestroke consultation.

Project description:The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.

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Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

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Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

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