PHILADELPHIA – A telemedicine program for patients with acute ischemic stroke increased the use of recombinant tissue plasminogen activator by as much as 13% in the year after implementation.
Most of the 13 hospitals in the retrospective study significantly increased their recombinant tissue plasminogen activator (rTPA) use, Dr. Jeffrey C. Wagner said at the annual meeting of the American Academy of Neurology. Three didn’t benefit, however, and one hospital actually experienced a significant decrease in rTPA administration.
rTPA "is the only treatment proven to benefit patients during acute ischemic stroke," said Dr. Wagner, a stroke specialist at Blue Sky Neurology in Denver.
"We obviously need more research to discover why these hospitals didn’t benefit more dramatically," he said.
The study population included patients aged 18 years and older who were admitted with a primary diagnosis of acute ischemic stroke and discharged between July 1, 2006, and Dec. 31, 2012; more than 15,000 patients were included in the retrospective analysis. Outcomes were extracted from a national claims database, and the hospitals had a minimum of 1 year of data available before and after implementing a telemedicine program. The hospitals represented a variety of patient demographics. About two-thirds were rural; approximately half were small, defined as fewer than 200 beds. The hospitals were located in the Northeastern, Southern, and Western portions of the United States.
The primary outcome was the percentage of patients treated with rTPA before and after telemedicine implementation.
Overall, rTPA administration increased significantly, from 4.5% to 7.3% after a telemedicine program was introduced. The increase was similar whether patients were admitted to the hospital or whether they were transferred to a stroke center.
There were, however, significant outcome differences among the hospitals according to size. Overall the use of rTPA in smaller hospitals increased from 1% to 7% after implementing a telemedicine program, compared with an increase from 5.4% to 7% in larger hospitals. Those results were similar when patients were stratified as inpatients or transferred patients.
Two hospitals increased rTPA use by more than 10%; five hospitals increased rTPA use by 5%-10%, and three hospitals increased rTPA use by 0-5%.
However, the rTPA use in three hospitals remained virtually identical; two administered no rTPA either before or after implementing a telemedicine program, and rTPA use in the third hospital increase from none to less than 2%. In addition, one of the largest hospitals in the study actually saw a 14% decrease in rTPA use, a finding Dr. Wagner was hard pressed to explain.
"In my experience, there’s a huge integrated system required for telemedicine to work well, from the EMS [emergency medical services] people calling in a stroke alert in advance to the emergency doctors activating the telemedicine system. My theory would be that there might not have been complete buy-in from the staff."
The three hospitals that didn’t experience any benefit were the smallest in the cohort – a factor that probably contributed to their lack of results, he added.
"My theory here is that they spanned the largest area of geography, so having telemedicine might not improve rTPA usage, because the real issue was not being able to get patients there in time," he said.
The study was funded by Genentech. Dr. Wagner had no additional disclosures.
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