Elevating Stroke Care: A Pharmacy Perspective on Telestroke Services

According to the CDC, a new stroke occurred in the United States every 40 seconds in 2023. Out of the 610,000 new strokes each year, approximately 87% were identified as ischemic strokes.¹

Availability of stroke care has grown substantially in the US over the past 15 years. In 2011, an estimated 20% of US residents lacked timely access to stroke care. As of 2019, that number plummeted to 4% of patients. A reason for this improved access was the implementation of telestroke services.² Timely access to specialized stroke care is crucial for improving outcomes and reducing burden of stroke-related disabilities.

In recent years, telestroke services have transformed stroke care delivery, especially in rural or underserved areas. Using technology to connect stroke specialists with local health care providers, telestroke services have helped fill the gap in accessing timely and expert stroke care. Telestroke services utilize remote stroke specialists who help guide local emergency physicians in reviewing imaging, diagnosing, treating, or transferring patients appropriately.³ These services have been important because, for ischemic stroke, the window to administer intravenous tissue plasminogen activator (tPA) or perform a mechanical thrombectomy is patient-specific and time-sensitive.²

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Impact on Thrombolysis Rates and Door-to-Needle Times

The primary objective of this study was to conduct a comprehensive analysis of the impact of telestroke implementation in the hospital setting. As literature surrounding intravenous tPA and endovascular mechanical thrombectomy has expanded, an ever-growing body of evidence supports reduced door-to-needle times, showing that this reduction has improved patient outcomes at discharge, reduced 1-year mortality rates, reduced readmission rates, and improved functional outcomes.^4-9

Barragan-Prieto et al found that before the implementation of a centralized telestroke network in Andalusia, Spain, only 59.72% of Andalusians had access to such care.¹⁰ However, after the implementation, this figure significantly increased to 93.45%, and the mean number of total reperfusion treatments per telestroke center per year also saw a significant rise.¹⁰ These authors provided tangible evidence of the positive impact of telestroke services on stroke care accessibility.

A 2023 systematic review concluded that there was no statistical significance between telestroke and non-telestroke medicine in terms of successful recanalization, discharge National Institutes of Health Stroke Scale/Score (NIHSS), or 90-day stroke-related mortality.¹² A retrospective chart review compared the effectiveness and safety of treating patients with acute ischemic stroke using either telestroke or in-person assessments. The study found no significant differences in time it took to administer treatment or 3-month mortality rates for patients assessed.¹³

Another study compared pre- and post-telestroke implementation composite scores for quality indicators and mortality up to 1-year post-stroke. In the post-implementation period, 14 of 17 quality indicators improved or remained the same, with door-to-needle times improving but not showing statistically significant differences. Lower patient mortality at both 6 and 12 months was observed in the post-implementation period.¹⁴

Ranta et al reported the impact of telestroke services on thrombolysis rates and door-to-needle times.¹⁵ The rates of thrombolysis increased significantly following the implementation of telestroke services, indicating a clear improvement in patient care. The overall average door-to-needle time was also significantly reduced after the implementation of telestroke services, further highlighting the efficiency and effectiveness of this approach.^15,16

Patient Outcomes and Health Care Efficiency

Jun-O'Connell and colleagues explored the differences in outcomes between telestroke consultation transfer patients (n=181) who received neurological treatment (63%) and those who did not receive any neurological intervention (37%). All patients included in the study were evaluated via telestroke consultation and transferred to the hub hospital. Overall mortality was not significantly different between the 2 groups (intervention 17.5%; non-intervention 10.4% the intervention group had a worse discharge NIHSS and modified Rankin Scale scores and a longer median length of stay. The 30-day readmission rates, 90-day mortality rates, and median 90-day modified ranking scale were similar. However, the median 90-day NIHSS was worse in the intervention group (P=0.004). The intervention group likely had a worse NIHSS and longer median length of stay because these patients were more complex than the non-intervention group.¹⁷

Three of 13 trials in this study reported 90-day mortality rates, with one reporting mortality rates at 6 and 12 months. While 90-day mortality rates were not statistically significantly different between in-person and telestroke assessments, they did trend towards a reduction. In one study that reported them, mortality rates at 6 and 12 months were both statistically significant. Three studies found varying effects of telestroke services on door-to-needle times for stroke patients, with 2 studies reporting significantly increased thrombolysis rates after implementing telestroke services. Although the available studies were limited, implementing telestroke services increased access to stroke care, which appears safer and more effective than standard care.

Conclusion

After conducting this literature review, it is suggested that the implementation of telestroke services in hospitals has demonstrated the potential to enhance access to stroke care, increase thrombolysis rates, and reduce 90-day post-stroke mortality, leading to improved overall patient outcomes.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). Stroke Facts. May 4, 2023. CDC website. Accessed January 16, 2024. https://www.cdc.gov/stroke/facts.htm

2. Zachrison KS, Cash RE, Adeoye O, et al. Estimated Population Access to Acute Stroke and Telestroke Centers in the US, 2019. JAMA Network Open. 2022;5(2):e2145824. doi:10.1001/jamanetworkopen.2021.45824

3. Richard JV, Wilcock AD, Schwamm LH, et al. Assessment of Telestroke Capacity in US Hospitals. JAMA Neurology. 2020;77(8):1035-1037. doi:10.1001/jamaneurol.2020.1274

4. Man, S., Solomon, N., Mac Grory, B., et al. Shorter Door-To-Needle Times are Associated with Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke. Circulation. 2023;148:20-34. doi:10.1161/CIRCULATIONAHA.123.064053

5. Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488. doi:10.1001/jama.2013.6959

6. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomized trials. Lancet. 2014;384:1929-1935. doi:10.1016/S0140-6736(14)60584-5

7. Fonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311:1632-1640. doi:10.1001/jama.2014.3203

8. Man S, Xian Y, Holmes DN, et al. Association between thrombolytic door-to-needle time and 1-year mortality and readmission in patients with acute ischemic stroke. JAMA. 2020;323:2170-2184. doi:10.1001/jama.2020.5697

9. Mulder M, Jansen I, Goldhoorn R, et al. Time to endovascular treatment and outcome in acute ischemic stroke: MR CLEAN Registry results. Circulation. 2018;138:232-240. doi:10.1161/CIRCULATIONAHA.117.032600

10. Barragan-Prieto A, Perez-Sanchez S, Moniche F, et al. Express improvement of acute stroke care accessibility in large regions using a centralized telestroke network. European Stroke Journal. 2022;7(3):259-266. doi:10.1177/23969873221101282

11. Poongkunran M, Ulep R, Stuntz G, et al. Diagnostic accuracy of telestroke consultation: a Louisiana based tele-network experience. Front Neurol. 2023;14:1141059. doi:10.3389/fneur.2023.1141059

12. Mohamed A, Elsherif S, Legere B, Fatima N, Shuaib A, Saqqur M. Is telestroke more effective than conventional treatment for acute ischemic stroke? A systematic review and meta-analysis of patient outcomes and thrombolysis rates. International Journal of Stroke. 2023. doi:10.1177/17474930231206066

13. Ho W, Fawcett A. Outcomes in patients with acute stroke treated at a comprehensive stroke center using telemedicine versus in-person assessments. Journal of Telemedicine and Telecare. 2023. doi:10.1177/1357633X231169115