Telestroke implementation did not change systems of care in hospitals

Researchers found no link between telestroke adoption and changes in stroke systems of care in a national sample of hospitals that implemented telestroke practices in EDs, according to a cross-sectional study published in JAMA Network Open.

“By introducing telestroke, we might imagine that it could lead to reorganization of the stroke system of care if patients are now able to stay in a hospital closer to home rather than be transported to a farther hospital or ultimately transferred to a different hospital with a higher level of resources,” Kori S. Zachrison, MD, MSc, of the department of emergency medicine at Massachusetts General Hospital in Boston, told Healio Neurology. “These things could potentially be avoided by bringing stroke expertise into a community that didn’t previously have access.

“We were interested in characterizing whether this was the case,” Zachrison continued. “In other words, would hospitals introducing telestroke capabilities in their EDs impact the organization of stroke systems and of where patients receive stroke care?”

To answer this question, Zachrison and colleagues analyzed data from 593 U.S. hospitals that adopted telestroke between 2009 and 2016 but were not comprehensive stroke centers, major teaching hospitals or thrombectomy-capable hospitals. They matched these hospitals with 593 control hospitals without telestroke to compare changes in stroke systems of care.

They matched the telestroke-equipped and control hospitals according to rural location (44%), critical access hospital status (21.9%), bed size, primary stroke center status (30.2%), presence of hospital alternatives in the community, hospital stroke volume, census region and ownership. Further, they identified all stroke and transient ischemic attack admissions between 2008 and 2018 using data on 100% of Medicare fee-for-service beneficiaries.

Zachrison and colleagues quantified the association between telestroke implementation and changes in care from 2 years prior to vs. 2 years after implementation using implementation dates of telestroke hospitals and a difference-in-differences approach for each hospital pair. They used models to control for differences in observed patient characteristics.

Hospital stroke volume, patients’ ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion and size of the receiving hospital for transferred patients served as main outcomes and measures.

Results showed similar changes in mean annual stroke volume in the pre-implementation vs. post-implementation periods at telestroke and control hospitals, with telestroke hospitals decreasing from 79.6 to 76.3 patients and control hospitals decreasing from 78.8 to 75.5 patients. Researchers observed no differences in ambulance transport distance, case mix, interhospital transfers or bed size of receiving hospitals among transferred patients.

“We were rather surprised to find that a hospital’s implementation of telestroke was not, in fact, associated with changes in these components of the stroke system of care that we studied,” Zachrison said. “If we do want telestroke to lead to a reorganization of stroke systems and improved allocation of patients within the system, then more work will have to be done.

“Introduction of telestroke in itself has not led to these changes, so perhaps we should consider more specific EMS protocols for prehospital transport, for example, or other interventions at the policy level,” Zachrison added.