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Majersik JJ, Wong KH, O'Donnell SM, Johnson J, Garcia-Esperon C, Hamilton BJ, Tekiela P, Ledyard HK, Taillac P. Telestroke value through the eyes of emergency medicine providers: A counterfactual analysis. Heliyon 2023; 9:e14767. [PMID: 37089373 PMCID: PMC10119505 DOI: 10.1016/j.heliyon.2023.e14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Objectives Emergency Medicine (EM) provider experiences consulting telestroke (TS) are poorly studied. In this qualitative study, we aimed to determine how TS changes patient management and to measure TS effects on EM provider confidence with acute ischemic stroke (AIS) treatment. Materials and methods We designed a survey for EM providers querying perceptions of TS value, confidence with treating AIS, and counterfactuals regarding what EM providers would have done without TS. Eligible EM providers participated in an audio-visual TS consult within a 6-state TS network between 11/2016-11/2017. Results We received 48 surveys (response rate 43%). The most common reason (71%) for using TS was tPA eligibility expert opinion. Most EM providers (94%) thought the patient/family were satisfied with TS and none felt their medical knowledge was doubted because of using TS. EM providers had high confidence in diagnosing AIS (95%) and tPA decision-making (86%), but not in determining thrombectomy eligibility (10%). Among EM providers who administered tPA, 85% said tPA would not have been given without TS consultation. TS consultation changed patient diagnosis in 60% of all patients and treatment plans in 56% of non-stroke patients. Most EM providers (86%) had increased confidence in their knowledge of future stroke patient management. Nearly all TS consults (93%) resulted in EM providers being more likely to use TS again. Conclusions TS consult frequently results in both patient management change and increased EM knowledge of stroke management with increased likelihood of repeat usage. Discomfort in determining eligibility for thrombectomy points to educational opportunities.
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Affiliation(s)
- Jennifer Juhl Majersik
- Neurology, University of Utah, United States
- Corresponding author. Third Floor Stroke Center, University of Utah, 175 N Medical Center Drive, Salt Lake City, UT 84132, United States.
| | - Ka-Ho Wong
- Department of Neurology, University of Utah, United States
| | | | | | | | | | - Piotr Tekiela
- Division of Vascular Neurology, Department of Neurology, University of Utah, United States
| | - Holly K. Ledyard
- Neurology and Emergency Medicine, University of Utah, United States
| | - Peter Taillac
- Emergency Medicine, University of Utah, United States
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2
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Turner J, Clarke M, George G, Jones RW, Pullinger R, Kharbanda R, Kennedy J, Hands L. Video-consultation in the Emergency Department: An Assessment of the Potential Benefit for a UK District General Hospital (Preprint). Interact J Med Res 2021; 11:e36081. [PMID: 36107488 PMCID: PMC9523531 DOI: 10.2196/36081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/15/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jane Turner
- Nuffield Department of Surgical Science, University of Oxford, Oxford, United Kingdom
| | - Malcolm Clarke
- Department of Electronic Engineering, Maynooth International Engineering College, Fuzhou, China
| | - Grizelda George
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | | | - Rick Pullinger
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Rajesh Kharbanda
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - James Kennedy
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Linda Hands
- Nuffield Department of Surgical Science, University of Oxford, Oxford, United Kingdom
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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Keating J, Borschmann K, Johns H, Churilov L, Bernhardt J. Young Stroke Survivors' Preferred Methods of Meeting Their Unique Needs: Shaping Better Care. Neurology 2021; 96:e1701-e1710. [PMID: 33568545 DOI: 10.1212/wnl.0000000000011647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine how young stroke survivors want their unmet needs to be addressed, we undertook an international online survey of people living with stroke. METHODS Participants self-selected to complete an online survey that included a questionnaire on demographics and stroke-related characteristics, the Young Stroke Needs Screening Tool, and a questionnaire on how they wanted their needs to be met. RESULTS One hundred seventy-one responses were received (68% female respondents, mean age 45 years, interquartile range 36-51 years). Preferences for methods of meeting needs varied depending on the domain of need and participants' demographic and stroke-related characteristics. Face-to-face contact with a health care professional was a popular means of meeting needs, but methods outside of a traditional health care setting such as a succinct list of tips or peer support were widely acceptable and sometimes preferred. CONCLUSION This work provides the impetus for developing alternative methods of meeting young stroke survivors' needs, many of which are not resource intensive or do not require an appointment with a health care professional.
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Affiliation(s)
- Jessica Keating
- From The Florey Institute of Neuroscience and Mental Health (J.K., K.B., H.J., J.B.), University of Melbourne, Heidelberg; St. Vincent's Hospital (K.B.), Melbourne; Austin Health Department of Medicine (L.C.), Heidelberg; Melbourne Brain Center (L.C.), Royal Melbourne Hospital; and Melbourne Medical School (L.C.), University of Melbourne, Australia
| | - Karen Borschmann
- From The Florey Institute of Neuroscience and Mental Health (J.K., K.B., H.J., J.B.), University of Melbourne, Heidelberg; St. Vincent's Hospital (K.B.), Melbourne; Austin Health Department of Medicine (L.C.), Heidelberg; Melbourne Brain Center (L.C.), Royal Melbourne Hospital; and Melbourne Medical School (L.C.), University of Melbourne, Australia
| | - Hannah Johns
- From The Florey Institute of Neuroscience and Mental Health (J.K., K.B., H.J., J.B.), University of Melbourne, Heidelberg; St. Vincent's Hospital (K.B.), Melbourne; Austin Health Department of Medicine (L.C.), Heidelberg; Melbourne Brain Center (L.C.), Royal Melbourne Hospital; and Melbourne Medical School (L.C.), University of Melbourne, Australia
| | - Leonid Churilov
- From The Florey Institute of Neuroscience and Mental Health (J.K., K.B., H.J., J.B.), University of Melbourne, Heidelberg; St. Vincent's Hospital (K.B.), Melbourne; Austin Health Department of Medicine (L.C.), Heidelberg; Melbourne Brain Center (L.C.), Royal Melbourne Hospital; and Melbourne Medical School (L.C.), University of Melbourne, Australia
| | - Julie Bernhardt
- From The Florey Institute of Neuroscience and Mental Health (J.K., K.B., H.J., J.B.), University of Melbourne, Heidelberg; St. Vincent's Hospital (K.B.), Melbourne; Austin Health Department of Medicine (L.C.), Heidelberg; Melbourne Brain Center (L.C.), Royal Melbourne Hospital; and Melbourne Medical School (L.C.), University of Melbourne, Australia.
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Abati E, Costamagna G. Education Research: Effect of the COVID-19 pandemic on neurology trainees in Italy: A resident-driven survey. Neurology 2020; 95:1061-1066. [PMID: 32938783 DOI: 10.1212/wnl.0000000000010878] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the effect of the coronavirus disease 2019 (COVID-19) outbreak on neurology resident training in Italy. METHOD We created a web-based survey regarding changes in clinical, research, and educational activity of neurology trainees in Italy during the COVID-19 pandemic and the preventive measures undertaken by local institutions to reduce the risk of contagion. RESULTS Seventy-nine residents working in Italy completed the survey. A total of 87.3% of trainees reported a substantial reduction in their neurologic duties since COVID-19 appeared in Italy, and 17.8% were also recruited or volunteered for COVID-19-dedicated wards. Likewise, more than 60% of trainees experienced a reduction or interruption in research activity. As regards the perceived effect of the COVID-19 outbreak on their neurologic training, almost 70% of surveyed trainees believe that the COVID-19 pandemic had or will have a negative effect on their formation as neurologists, for different reasons. Furthermore, trainees reported a consistent exposure (69.6%) to confirmed positive COVID-19 cases at work, with divergent surveillance and preventive measures taken by local institutions. CONCLUSIONS Overall, the survey shows that the COVID-19 pandemic in Italy has had a subjective negative effect on neurology residents on didactics, clinical, and research training as well as training abroad. The COVID-19 outbreak poses many challenges to academic institutions and training programs, and addressing these issues promptly is crucial to ensure continued quality of trainees' neurologic education. Sharing solutions and ideas among the international neurologic community might help neurology training programs worldwide to better counteract these problems.
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Affiliation(s)
- Elena Abati
- From the Department of Pathophysiology and Transplantation, Dino Ferrari Centre, Neuroscience Section, University of Milan, Italy.
| | - Gianluca Costamagna
- From the Department of Pathophysiology and Transplantation, Dino Ferrari Centre, Neuroscience Section, University of Milan, Italy
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Telemedicine in the Era of Coronavirus Disease 2019 (COVID-19): A Neurosurgical Perspective. World Neurosurg 2020; 139:549-557. [PMID: 32426065 PMCID: PMC7229725 DOI: 10.1016/j.wneu.2020.05.066] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 11/23/2022]
Abstract
Despite the substantial growth of telemedicine and the evidence of its advantages, the use of telemedicine in neurosurgery has been limited. Barriers have included medicolegal issues surrounding provider reimbursement, interstate licensure, and malpractice liability as well as technological challenges. Recently, the coronavirus disease 2019 (COVID-19) pandemic has limited typical evaluation of patients with neurologic issues and resulted in a surge in demand for virtual medical visits. Meanwhile, federal and state governments took action to facilitate the rapid implementation of telehealth programs, placing a temporary lift on medicolegal barriers that had previously limited its expansion. This created a unique opportunity for widespread telehealth use to meet the surge in demand for remote medical care. After initial hurdles and challenges, our experience with telemedicine in neurosurgery at Penn Medicine has been overall positive from both the provider and the patients' perspective. One of the unique challenges we face is guiding patients to appropriately set up devices in a way that enables an effective neuroexamination. However, we argue that an accurate and comprehensive neurologic examination can be conducted through a telemedicine platform, despite minor weaknesses inherent to absence of physical presence. In addition, certain neurosurgical visits such as postoperative checks, vascular pathology, and brain tumors inherently lend themselves to easier evaluation through telehealth visits. In the era of COVID-19 and beyond, telemedicine remains a promising and effective approach to continue neurologic patient care.
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Halbert K, Bautista C. Telehealth Use to Promote Quality Outcomes and Reduce Costs in Stroke Care. Crit Care Nurs Clin North Am 2019; 31:133-139. [DOI: 10.1016/j.cnc.2019.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nathaniel TI, Ubah C, Wormack L, Gainey J. The telestroke and thrombolysis therapy in diabetic stroke patients. Diabetol Metab Syndr 2019; 11:36. [PMID: 31086570 PMCID: PMC6506930 DOI: 10.1186/s13098-019-0421-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/02/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Several controversial findings have been reported on treatment outcomes for diabetic stroke patients that received thrombolysis therapy in the hospital. We determined whether the association between telestroke technology, thrombolysis therapy and clinical risk factors in diabetic acute ischemic stroke may result in the inclusion or exclusion or more diabetic ischemic stroke patients for thrombolysis therapy. METHODS Retrospective data that comprises of a total of 3202 acute ischemic stroke patients from a regional stroke registry that contained telestroke and non telestroke patients with a primary diagnosis of acute ischemic stroke of which 312 were identified as diabetic stroke patients were used in this study. Multivariate logistic regression models were used to determine the associated pre-clinical risk factors, and demographics associated with recombinant tissue plasminogen activator (rtPA) therapy in a subset of diabetic acute ischemic stroke patients in the telestroke and non-telestroke settings. RESULTS In the telestroke, only higher International Normalized Ratio (INR) [odds ratio, OR = 0.063 (0.003-1.347, 95% confidence interval (CI)] was associated with exclusion from thrombolysis. Direct admission [OR, 3.141 (1-9.867), 95% CI] and telestroke [OR, 4.87 (1.834-12.928), 95% CI] were independent predictors in the inclusion for thrombolysis therapy. In the non telestroke, older age (> 80 years) [(OR), 0.955 (0.922-0.989), 95% CI], higher blood glucose level [OR, 0.994 (0.99-0.999); 95% CI], higher INR [OR, 0.113 (0.014-0.944); 95% CI], and renal insufficiency [OR, 0.163 (0.033-0.791); 95% CI] were associated with exclusion while higher NIH stroke scale [OR, 1.068 (1.009-1.13); 95% CI] was associated with inclusion for thrombolysis in the non telestroke. CONCLUSION The non-telestroke setting admitted more diabetic stroke patients to the hospital, but more were excluded from thrombolysis therapy when compared with the telestroke setting. Measures to improve clinical risk factors that excluded more diabetic ischemic stroke patients in the non telestroke will improve the use of thrombolysis in the treatment of diabetic acute ischemic stroke patients.
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Affiliation(s)
- Thomas I. Nathaniel
- School of Medicine-Greenville, University of South Carolina, Greenville, SC 29605 USA
| | - Chibueze Ubah
- School of Medicine-Greenville, University of South Carolina, Greenville, SC 29605 USA
| | - Leah Wormack
- School of Medicine-Greenville, University of South Carolina, Greenville, SC 29605 USA
| | - Jordan Gainey
- School of Medicine-Greenville, University of South Carolina, Greenville, SC 29605 USA
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9
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Mase A, Ryan S, Mader G, Alvarez A, Armitige L, Chen L, McSherry G, Wilson J, Mase S, Banerjee R. Pediatric tuberculosis consultations across 5 CDC regional tuberculosis training and medical consultation Centers. J Clin Tuberc Other Mycobact Dis 2018; 11:23-27. [PMID: 31720388 PMCID: PMC6830164 DOI: 10.1016/j.jctube.2018.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/07/2018] [Accepted: 04/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The U.S. Centers for Disease Control and Prevention (CDC) funds five Regional Tuberculosis Training and Medical Consultation Centers (RTMCCs) that provide training and consultation for tuberculosis (TB) control and management. RTMCC utilization for assistance with diagnosis and management of TB in children has not been described. We analyzed pediatric TB consultations performed across all RTMCCs in terms of question type, provider type, and setting. METHODS The CDC medical consultation database was queried for consultations regarding patients ≤ 18 years provided between 1/1/13-4/22/15 by all RTMCCs (Curry International TB Center, Heartland National TB Center, Mayo Clinic Center for TB, New Jersey Medical School Global TB Institute, Southeastern National TB Center). Each query was categorized into multiple subject areas based on provider type, setting, consultation topic, and patient age. RESULTS The 5 RTMCCs received 1164 pediatric consultation requests, representing approximately 20% of all consultations performed by the centers during the study period. Providers requesting consults were primarily physicians (46.3%) or nurses (45.0%). The majority of pediatric consult requests were from state and local public health departments (679, 58.3%) followed by hospital providers (199, 17.1%); fewer requests came from clinicians in private practice (84, 7.2%) or academic institutions (40, 3.4%). Consults addressed 14 different topics, most commonly management of children with TB disease (19.1%), latent TB infection (LTBI) (18.2%), diagnosis or laboratory testing (18.7%), and pharmacology (9.2%). DISCUSSION Pediatric consultations accounted for approximately 20% of all consultations performed by RTMCCs during the study period. RTMCCs were utilized primarily by public health departments regarding management of TB disease, LTBI, and diagnosis or laboratory testing. The relative underutilization of the RTMCCs by clinicians in non-public health settings, who often manage children with TB exposure or infection, warrants further study. As US TB case rates decline and providers become less experienced with childhood TB, medical consultation support may become increasingly important.
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Affiliation(s)
| | - Stephen Ryan
- Southeastern National Tuberculosis Center, Gainesville, FL, USA
| | | | - Ana Alvarez
- University of Florida, Jacksonville, FL, USA
| | - Lisa Armitige
- University of Texas-Health Northeast, San Antonio, TX, USA
| | - Lisa Chen
- University of California, San Francisco, CA, USA
| | | | | | - Sundari Mase
- Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and Management of Acute Ischemic Stroke. Mayo Clin Proc 2018; 93:523-538. [PMID: 29622098 DOI: 10.1016/j.mayocp.2018.02.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/25/2018] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
Acute ischemic stroke (AIS) is among the leading causes of death and long-term disability. Intravenous tissue plasminogen activator has been the mainstay of acute therapy. Recently, several prospective randomized trials documented the value of endovascular revascularization in selected patients with large-vessel occlusion within the anterior circulation. This finding has led to a paradigm shift in the management of AIS, including wide adoption of noninvasive neuroimaging to assess vessel patency and tissue viability, with the supplemental and independent use of intravenous tissue plasminogen activator to improve clinical outcomes. In this article, we review the landmark studies on management of AIS and the current position on the diagnosis and management of AIS. The review also highlights the importance of early stabilization and prompt initiation of therapeutic interventions before, during, and after the diagnosis of AIS within and outside of the hospital.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Neil Haranhalli
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Scott L Silliman
- Department of Neurology, University of Florida Health Science Center, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
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Zhao Y, Guthridge S, Falhammar H, Flavell H, Cadilhac DA. Cost-effectiveness of stroke care in Aboriginal and non-Aboriginal patients: an observational cohort study in the Northern Territory of Australia. BMJ Open 2017; 7:e015033. [PMID: 28982808 PMCID: PMC5640075 DOI: 10.1136/bmjopen-2016-015033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess cost-effectiveness of stroke care for Aboriginal compared with non-Aboriginal patients in the Northern Territory (NT), Australia. DESIGN Cost-effectiveness analysis using data from a cohort-based follow-up study of stroke incidents. SETTING Public hospitals in the NT from 1992 to 2013. PARTICIPANTS Individual patient data were extracted and linked from the hospital inpatient and primary care information systems. OUTCOME MEASURES Incremental cost-effectiveness ratios were calculated and assessed graphically. Survival time was used to measure effectiveness of stroke care, in comparison with the net costs per life-year gained, from a healthcare perspective, by applying multivariable models to account for time-dependent confounding. RESULTS 2158 patients with incident stroke were included (1171 males, 1178 aged <65 years and 966 from remote areas). 992 patients were of Aboriginal origin (46.0%, disproportionately higher than the population proportion of 27%). Of all cases, 42.6% were ischaemic and 29.8% haemorrhagic stroke. Average age of stroke onset was 51 years in Aboriginal, compared with 65 years in non-Aboriginal patients (p<0.001). Aboriginal patients had 71.4% more hospital bed-days, and 7.4% fewer procedures than non-Aboriginal patients. Observed health costs averaged $A50 400 per Aboriginal compared with $A33 700 per non-Aboriginal patient (p<0.001). The differential costs and effects for each population were distributed evenly across the incremental cost-effectiveness plane threshold line, indicating no difference in cost-effectiveness between populations. After further adjustment for confounding and censoring, cost-effectiveness appeared greater for Aboriginal than non-Aboriginal patients, but this was not statistically significant (p=0.25). CONCLUSIONS Stroke care for the NT Aboriginal population is at least as cost-effective as the non-Aboriginal population. Stroke care presents worthwhile and equitable survival benefits for Aboriginal patients in remote communities, notwithstanding their higher level burden of disease. These findings are relevant for healthcare planning and policy development regarding equal access to stroke care for Aboriginal patients.
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Affiliation(s)
- Yuejen Zhao
- Health Gains Planning, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Steven Guthridge
- Health Gains Planning, Northern Territory Department of Health, Darwin, Northern Territory, Australia
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Henrik Falhammar
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Howard Flavell
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Population Health Research, Deakin University, Geelong, Victoria, Australia
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12
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Van Oeveren L, Donner J, Fantegrossi A, Mohr NM, Brown CA. Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study. Telemed J E Health 2016; 23:290-297. [PMID: 27673565 DOI: 10.1089/tmj.2016.0140] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. INTRODUCTION We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. MATERIALS AND METHODS Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. RESULTS Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. DISCUSSION The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. CONCLUSIONS Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.
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Affiliation(s)
- Lucas Van Oeveren
- 1 Section of Emergency Medicine, Avera McKennan Hospital , Sioux Falls, South Dakota.,2 Avera eCARE, Avera Health System , Sioux Falls, South Dakota
| | - Julie Donner
- 2 Avera eCARE, Avera Health System , Sioux Falls, South Dakota
| | - Andrea Fantegrossi
- 3 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Nicholas M Mohr
- 4 Department of Emergency Medicine, Division of Critical Care, University of Iowa Carver College of Medicine , Iowa City, Iowa.,5 Department of Anesthesia, University of Iowa Carver College of Medicine , Iowa City, Iowa
| | - Calvin A Brown
- 3 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,6 Harvard Medical School , Boston, Massachusetts
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Yuan Z, Wang B, Li F, Wang J, Zhi J, Luo E, Liu Z, Zhao G. Intravenous thrombolysis guided by a telemedicine consultation system for acute ischaemic stroke patients in China: the protocol of a multicentre historically controlled study. BMJ Open 2015; 5:e006704. [PMID: 25979867 PMCID: PMC4442242 DOI: 10.1136/bmjopen-2014-006704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The rate of intravenous thrombolysis with tissue-type plasminogen activator or urokinase for stroke patients is extremely low in China. It has been demonstrated that a telestroke service may help to increase the rate of intravenous thrombolysis and improve stroke care quality in local hospitals. The aim of this study, also called the Acute Stroke Advancing Program, is to evaluate the effectiveness and safety of decision-making concerning intravenous thrombolysis via a telemedicine consultation system for acute ischaemic stroke patients in China. METHODS AND ANALYSIS This is a multicentre historically controlled study with a planned enrolment of 300 participants in each of two groups. The telestroke network consists of one hub hospital and 14 spoke hospitals in underserved regions of China. The usual stroke care quality in the spoke hospitals without guidance from the hub hospital will be used as the historical control. The telemedicine consultation system is an interactive, two-way, wireless, audiovisual system accessed on portable devices. The primary outcome is the percentage of patients treated with intravenous thrombolysis within 4.5 h of stroke onset. ETHICS AND DISSEMINATION The project has been approved by the Institutional Review Board of Xijing Hospital. The results will be published in scientific journals and presented to local government and relevant institutes. TRIAL REGISTRATION NUMBER NCT02088346 (12 March 2014).
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Affiliation(s)
- Ziwen Yuan
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, Xìan, China
| | - Bo Wang
- Department of Epidemiology, The Fourth Military Medical University, Xìan, China
| | - Feijiang Li
- School of Biomedical Engineering, The Fourth Military Medical University, Xìan, China
| | - Jing Wang
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, Xìan, China
| | - Jin Zhi
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, Xìan, China
| | - Erping Luo
- School of Biomedical Engineering, The Fourth Military Medical University, Xìan, China
| | - Zhirong Liu
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, Xìan, China
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, Xìan, China
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14
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Freeman WD, Barrett KM, Vatz KA, Demaerschalk BM. Future neurohospitalist: teleneurohospitalist. Neurohospitalist 2013; 2:132-43. [PMID: 23983878 DOI: 10.1177/1941874412450714] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time. Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services. Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option. The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected. We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.
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Affiliation(s)
- William David Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA ; Department of Critical Care, Mayo Clinic, Jacksonville, FL, USA
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15
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Juzoji H. Legal Bases for Medical Supervision via Mobile Telecommunications in Japan. INTERNATIONAL JOURNAL OF E-HEALTH AND MEDICAL COMMUNICATIONS 2012. [DOI: 10.4018/jehmc.2012010103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper discusses the legal basis for mobile telecommunications-based medical supervision in Japan and bulletin from the Ministry of Health, Labour and Welfare. According to Article 44 of the Emergency Life-Saving Technician’s Act, an emergency technician shall not perform certain emergency medical procedures unless specifically authorized to do so by a medical practitioner. Actual conditions make these requirements unwieldy to put into practice. When requested to provide medical control in response to an ambulance call, a licensed physician has no choice but to allow the emergency technician to administer medical care. These circumstances expose medical practitioners to significant legal risks and societal ramifications. Is a mobile telecommunications environment characterized by insufficient information satisfactory for the medical care needed in ambulances? This paper discusses such medical care and its legal ramifications, including: how to implement such medical care under Article 21 of the Basic Act on Establishing a Networked Society Based on Advanced Information and Telecommunications. The Japanese government is obligated to provide citizens with broadband telecommunication lines in the near future to enable the smooth implementation of medical control over medical supervision provided in ambulances.
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16
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Kahn JM, Hill NS, Lilly CM, Angus DC, Jacobi J, Rubenfeld GD, Rothschild JM, Sales AE, Scales DC, Mathers JAL. The research agenda in ICU telemedicine: a statement from the Critical Care Societies Collaborative. Chest 2011; 140:230-238. [PMID: 21729894 PMCID: PMC3130530 DOI: 10.1378/chest.11-0610] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 03/15/2011] [Indexed: 11/01/2022] Open
Abstract
ICU telemedicine uses audiovisual conferencing technology to provide critical care from a remote location. Research is needed to best define the optimal use of ICU telemedicine, but efforts are hindered by methodological challenges and the lack of an organized delivery approach. We convened an interdisciplinary working group to develop a research agenda in ICU telemedicine, addressing both methodological and knowledge gaps in the field. To best inform clinical decision-making and health policy, future research should be organized around a conceptual framework that enables consistent descriptions of both the study setting and the telemedicine intervention. The framework should include standardized methods for assessing the preimplementation ICU environment and describing the telemedicine program. This framework will facilitate comparisons across studies and improve generalizability by permitting context-specific interpretation. Research based on this framework should consider the multidisciplinary nature of ICU care and describe the specific program goals. Key topic areas to be addressed include the effect of ICU telemedicine on the structure, process, and outcome of critical care delivery. Ideally, future research should attempt to address causation instead of simply associations and elucidate the mechanism of action in order to determine exactly how ICU telemedicine achieves its effects. ICU telemedicine has significant potential to improve critical care delivery, but high-quality research is needed to best inform its use. We propose an agenda to advance the science of ICU telemedicine and generate research with the greatest potential to improve patient care.
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Affiliation(s)
- Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, MA
| | - Craig M Lilly
- Department of Medicine, University of Massachusetts, Amherst, MA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | | | - Anne E Sales
- Department of Nursing, University of Alberta, Edmonton, AB, Canada
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17
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Waldura JF, Neff S, Goldschmidt RH. Teleconsultation for clinicians who provide human immunodeficiency virus care: experience of the national HIV telephone consultation service. Telemed J E Health 2011; 17:472-7. [PMID: 21612517 DOI: 10.1089/tmj.2010.0210] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine the infrastructure, successes, and challenges of a teleconsultation service for human immunodeficiency virus (HIV) clinicians. MATERIALS AND METHODS The HIV Warmline is a telephone consultation service providing free, live HIV/AIDS management advice to U.S. clinicians. We present descriptive data about callers, patients, and consultation topics gathered by electronic query of the HIV Warmline database for 2009. Caller satisfaction survey results for 2009 are also presented. RESULTS The HIV Warmline has provided more than 37,000 consultations since its inception in 1992. The service provides consultations to clinicians from all 50 states, from a variety of professional backgrounds, and with a wide range of HIV experience levels. The majority of call topics concern antiretroviral therapy. Callers are generally pleased with the service, giving a mean Likert scale rating of 4.7 on satisfaction survey questions. CONCLUSION The experience of the HIV Warmline can serve as a model for other programs planning to develop remote consultation systems. HIV teleconsultation has been relatively simple to implement and can be useful for many types of clinicians. HIV teleconsultation should continue to be evaluated as a way to improve HIV care, especially in areas without easy access to HIV expertise.
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Affiliation(s)
- Jessica F Waldura
- Department of Family and Community Medicine, National HIV/AIDS Clinicians' Consultation Center (NCCC), San Francisco General Hospital, University of California, San Francisco, California, USA
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18
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Richter GM, Sun G, Lee TC, Chan RP, Flynn JT, Starren J, Chiang MF. Speed of telemedicine vs ophthalmoscopy for retinopathy of prematurity diagnosis. Am J Ophthalmol 2009; 148:136-42.e2. [PMID: 19376496 PMCID: PMC2820880 DOI: 10.1016/j.ajo.2009.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 02/02/2009] [Accepted: 02/03/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare the speed of retinopathy of prematurity (ROP) diagnosis using standard indirect ophthalmoscopy with that of telemedicine. DESIGN Prospective, comparative study. METHODS Three study examiners (2 pediatric retinal specialists [R.V.P.C., T.C.L.] and 1 pediatric ophthalmologist [M.F.C.]) conducted ROP diagnosis via standard indirect ophthalmoscopy and telemedicine. Each examiner performed: 1) standard ophthalmoscopy on 72 to 150 consecutive infants at his respective institution and 2) telemedical diagnosis on 125 consecutive deidentified retinal image sets from infants from an at-risk population. Time for ophthalmoscopic diagnosis was measured in 2 ways: 1) time spent by the examiner at the infant's bedside and 2) mean total time commitment per infant. Time for telemedicine diagnosis was recorded by computer time stamps in the web-based system. For each examiner, nonparametric statistical analysis (Mann-Whitney U test) was used to compare the distribution of times for examination by ophthalmoscopy vs telemedicine. RESULTS Mean (+/- standard deviation [SD]) times for ophthalmoscopic diagnosis ranged from 4.17 (+/- 1.34) minutes to 6.63 (+/- 2.28) minutes per infant. Mean (+/- SD) times for telemedicine diagnosis ranged from 1.02 (+/- 0.27) minutes to 1.75 (+/- 0.80) minutes per infant. Telemedicine was significantly faster than ophthalmoscopy (P < .0001). The total time commitment by ophthalmologists performing bedside ophthalmoscopy for ROP diagnosis, including travel and communication with families and hospital staff, was 10.08 (+/- 2.53) minutes to 14.42 (+/- 2.64) minutes per infant. CONCLUSIONS The ophthalmologist time requirement for telemedical ROP diagnosis is significantly less than that for ophthalmoscopic diagnosis. Additional time requirements associated with bedside ROP diagnosis increased this disparity. Telemedicine has potential to alleviate the time commitment for ophthalmologists who manage ROP.
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Affiliation(s)
- Grace M. Richter
- Department of Ophthalmology, Columbia University College of Physicians and Surgeons, New York, NY
- Columbia University Mailman School of Public Health, New York, NY
| | - Grace Sun
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY
| | - Thomas C. Lee
- The Vision Center, Childrens Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA
| | - R.V. Paul Chan
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY
| | - John T. Flynn
- Department of Ophthalmology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Justin Starren
- Biomedical Informatics Research Center, Marshfield Clinic, Marshfield, WI
- Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Michael F. Chiang
- Department of Ophthalmology, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, NY
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