Recent advances in TeleStroke: a systematic review on applications in prehospital management and Stroke Unit treatment or TeleStroke networking in developing countries

Developing Systems of Care for Stroke in Resource-limited Settings

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis

IMPORTANCE

So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care.

OBJECTIVE

To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS).

DATA SOURCES

MEDLINE, Cochrane Library, and Embase from 1960 to 2021.

STUDY SELECTION

Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies.

DATA EXTRACTION AND SYNTHESIS

Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days).

RESULTS

Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT.

CONCLUSIONS AND RELEVANCE

Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.

Stroke Care in the First Affiliated Hospital of Chengdu Medical College during the COVID-19 Outbreak

Coronavirus disease-2019 (COVID-19) has become a pandemic disease globally. The First Affiliated Hospital of Chengdu Medical College has adopted telestroke to make stroke care accessible in remote areas. During the period January 2020 to March 2020, there was no COVID-19 case reported in our stroke center. A significant reduction of stroke admission was observed between the ischemic stroke group (235 vs. 588 cases) and the intracerebral hemorrhage group (136 vs. 150 cases) when compared with the same period last year (p < 0.001). The mean door-to-needle time (DNT) and door-to-puncture time (DPT) was 62 and 124 min, respectively. Compared to the same period last year, a significant change was observed in DNT (62 ± 12 vs. 47 ± 8 min, p = 0.019) but not in DPT (124 ± 58 vs. 135 ± 23 min, p = 0.682). A total of 46 telestroke consultations were received from network hospitals. Telestroke management in the central hospital was performed on 17 patients. Of them, 3 (17.6%) patients had brain hernia and died in hospital and 8 (47.1%) patients were able to ambulation at discharge and had a modified Rankin Scale of 0–2 at 3 months. The COVID-19 pandemic impacted stroke care significantly in our hospital, including prehospital and in-hospital settings, resulting in a significant drop in acute ischemic stroke admissions and a delay in DNT. The construction of a telestroke network enabled us to extend health-care resources and make stroke care accessible in remote areas. Stroke education and public awareness should be reinforced during the COVID-19 pandemic.

A systematic review of the cost-effectiveness of emergency interventions for stroke in low- and middle-income countries

Background

Stroke is a leading cause of death and disability globally, with an increasing incidence in low- and middle-income countries (LMICs). The successful treatment of acute stroke requires an organized, efficient and well-resourced emergency care system. However, debate exists surrounding the prioritization of stroke treatment programs given the high costs of treatment and the increased incidence of hemorrhagic stroke in LMICs. Economic data is helpful to guide evidence-based priority setting in health systems development, particularly in low-resource settings where scarcity requires careful stewardship of resources. This systematic review surveys the existing evidence surrounding the cost-effectiveness of interventions to address acute stroke in LMIC settings.

Methods

The authors conducted a PRISMA style systematic review of economic evaluations of interventions to address acute stroke in LMICs. Five databases were systematically searched for articles, which were then reviewed for inclusion.

Results

Of the 153 unique articles identified, 11 met the inclusion criteria. Four studies demonstrate the heavy economic burden on patients and households due to stroke. Two studies estimate that preventive measures are more cost-effective than acute treatments. Four studies directly examine the cost-effectiveness of thrombolysis and thrombectomy in three middle-income countries (Iran, China, and Brazil) with results ranging from roughly $2578 to $34,052 (2019 USD) per quality adjusted life-year saved. These results are similar to the cost-effectiveness ratios estimated in high-income settings. Finally, one study examined a care bundle that included acute treatment elements.

Conclusions

The findings reinforce the need for additional research support informed decision-making. The available evidence suggests that preventive measures should be prioritized over emergency treatment for acute stroke, particularly in settings of resource scarcity. Cost-effectiveness ratios do not compare favorably to estimates for other emergency care interventions in LMICs, such as basic emergency care training, implementation of triage systems, and basic trauma care. Cost-effectiveness is also likely to vary depending on local epidemiology. Overall, decision-makers should balance the economic evidence alongside social, political and cultural priorities when making resource allocation choices.

Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review

Background

Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation.

Objective

Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care.

Methods

This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently.

Results

Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use; however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes.

Conclusions

The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.

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

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.

Effects of increased distance to urgent and emergency care facilities resulting from health services reconfiguration: a systematic review

Background

Service reconfigurations sometimes increase travel time and/or distance for patients to reach their nearest hospital or other urgent and emergency care facility. Many communities value their local services and perceive that proposed changes could worsen outcomes for patients.

Objectives

To identify, appraise and synthesise existing research evidence regarding the outcomes and impacts of service reconfigurations that increase the time and/or distance for patients to reach an urgent and emergency care facility. We also aimed to examine the available evidence regarding associations between distance to a facility and outcomes for patients and health services, together with factors that may influence (moderate or mediate) these associations.

Data sources

We searched seven bibliographic databases in February 2019. The search was supplemented by citation-tracking and reference list checking. A separate search was conducted to identify the current systematic reviews of telehealth to support urgent and emergency care.

Methods

Brief inclusion and exclusion criteria were as follows: (1) population – adults or children with conditions that required emergency treatment; (2) intervention/comparison – studies comparing outcomes before and after a service reconfiguration, which affects the time/distance to urgent and emergency care or comparing outcomes in groups of people travelling different distances to access urgent and emergency care; (3) outcomes – any patient or health system outcome; (4) setting – the UK and other developed countries with relevant health-care systems; and (5) study design – any. The search results were screened against the inclusion criteria by one reviewer, with a 10% sample screened by a second reviewer. A quality (risk-of-bias) assessment was undertaken using The Joanna Briggs Institute Checklist for Quasi-Experimental Studies. We performed a narrative synthesis of the included studies and assessed the overall strength of evidence using a previously published method.

Results

We included 44 studies in the review, of which eight originated from the UK. For studies of general urgent and emergency care populations, there was no evidence that reconfiguration that resulted in increased travel time/distance affected mortality rates. By contrast, evidence of increased risk was identified from studies restricted to patients with acute myocardial infarction. Increases in mortality risk were most obvious within the first 1–4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. In the absence of reconfiguration, evidence mainly from cohort studies indicated that increased travel time or distance is associated with increased mortality risk for the acute myocardial infarction and trauma populations, whereas for obstetric emergencies the evidence was inconsistent. We included 12 systematic reviews of telehealth. Meta-analyses suggested that telehealth technologies can reduce time to treatment for people with stroke and ST elevation myocardial infarction.

Limitations

Most studies came from non-UK settings and many were at high risk of bias because there was no true control group. Most review processes were carried out by a single reviewer within a constrained time frame.

Conclusions

We found no evidence that increased distance increases mortality risk for the general population of people requiring urgent and emergency care, although this may not be true for people with acute myocardial infarction or trauma. Increases in mortality risk were most likely in the first few years after reconfiguration.

Future work

Research is needed to better understand how health systems plan for and adapt to increases in travel time, to quantify impacts on health system outcomes, and to address the uncertainty about how risk increases with distance in circumstances relevant to UK settings.

Study registration

This study is registered as PROSPERO CRD42019123061.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 31. See the NIHR Journals Library website for further project information.

Evaluation of the triple aim of medicine in prehospital telemedicine: A systematic literature review

OBJECTIVES

With telemedicine becoming more widely implemented in emergency situations, understanding the quality and content of current findings that explore prehospital telemedicine is vital to establish best practices and guide future research. This systematic review examines the clinical importance of telemedicine in patient-provider ambulance-based settings with a focus on multifunctional systems for general prehospital emergency populations.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology we found 1564 abstracts, which were blind-reviewed by independent reviewers. Relevant articles were reviewed, classified, and analyzed according to research methods and technology type, as well as quality, cost, and satisfaction. The studies were also reviewed for validated evidence-based practice.

RESULTS

Those studies that looked at cost, quality, and satisfaction with care generally shared favorable results. Setup notwithstanding, cost was comparable or less than controls. Care quality was also found to be in line with or slightly preferable to face-to-face care with some advantages in response time and quality. Patients and providers were satisfied with the systems. Common obstacles included limited bandwidth and small sample sizes.

CONCLUSIONS

Although feasibility remains salient, research regarding the impact of ambulance-based telemedicine on patients and healthcare providers is encouraging, but nascent. As a whole, this body of literature does not yet adequately speak to the most important concerns of medicine: quality, cost, and satisfaction. More research is needed in each of these areas. However, those studies that do address these matters share hopeful results. Future research should test these mechanisms in prehospital settings with greater rigor.

Telesonography in emergency medicine: A systematic review

Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.

How to do health services research in stroke: A focus on performance measurement and quality improvement

The objective of this "How to" research series article is to provide guidance on getting started in Health Services Research. The purpose of health services research is to contribute knowledge that can be used to help improve health systems and clinical services through influencing policy and practice. The methods used are broad, have varying levels of rigor, and may require different specialist skills. This paper sets out practical steps for undertaking health services research. Importantly, use of the highlighted techniques can identify solutions to address inadequate knowledge translation or promote greater access to evidence-based stroke care to optimize patient outcomes.

Outcomes following telestroke-assisted thrombolysis for stroke in Ontario, Canada

Introduction Since 2002, the Ontario Telestroke Program has provided hospitals in under-served regions of the province the opportunity to offer intravenous thrombolysis with tissue plasminogen activator (IV tPA) to eligible patients. The purpose of this study was to determine whether telestroke-assisted IV tPA patients had similar risks of 7- and 90-day mortality, symptomatic intracerebral haemorrhage (sICH), and poor functional outcome compared to patients who received IV tPA with on-site expertise. Methods Data from two audits of patients with acute ischaemic stroke hospitalized in Ontario, Canada in 2010 and 2012 were analysed. We modelled the risk of all-cause death within 7 and 90 days of receiving IV tPA using proportional hazards adjusting for hospital type, patient characteristics, and whether IV tPA was administered as part of a telestroke consultation. Outcomes of sICH and modified Rankin Scale ≥ 3 at discharge were modelled using generalized estimating equations adjusting for the same variables used in the mortality model. Results There was no difference in 7- or 90-day mortality among those who received IV tPA with telestroke ( n = 214) compared to those without ( n = 1885) (7-day adjusted hazard ratio (aHR) 1.29 (95% confidence interval (CI) 0.68, 2.44); 90-day aHR 1.01 (95% CI 0.67, 1.50)). Complications were similar between groups, with an adjusted odds ratio (aOR) for sICH of 0.71 (95% CI 0.29, 1.71) and an aOR of 0.75 (95% CI 0.46, 1.23) for poor functional ability at discharge. Discussion Patients receiving IV tPA supported by telestroke had similar outcomes to those managed with on-site expertise.

Recent advances in the management of acute ischemic stroke

In recent years, several landmark trials have transformed acute ischemic stroke care. The most dramatic results from the field of acute endovascular intervention demonstrate unequivocal benefit for a select group of patients with moderate to severe deficits presenting within 7 hours from onset and with occlusions of proximal arteries in the anterior circulation. In addition, technological advances and workflow efficiencies have facilitated more rapid delivery of acute stroke interventions. This review provides an overview of recent advances in the management of acute ischemic stroke.

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

What drives attitude towards telemedicine among families of pediatric patients? A survey

BACKGROUND

Telemedicine has been recognized as a way to improve accessibility, quality, and efficiency of care. In view of the introduction of new telemedicine services, we conducted a survey through a self-administered questionnaire among families of children attending the Bambino Gesù Children's Hospital IRCCS, a tertiary care children's hospital located in Rome, Italy.

METHODS

We investigated sociodemographic data, clinical information, technological profile, attitude towards telemedicine, perceived advantages of telemedicine, fears regarding telemedicine, willingness to use a smartphone app providing telemedicine services and willingness to use a televisit service. Through logistic regression, we explored the effect of sociodemographic and clinical variables and technological profile on willingness of using a telemedicine app and a televisit service.

RESULTS

We enrolled a total of 751 families. Most patients had a high technological profile, 81% had at least one account on a social network. Whatsapp was the most popular messaging service (76%). Seventy-two percent of patients would use an app for telemedicine services and 65% would perform a televisit. Owning a tablet was associated with both outcome variables - respectively: OR 2.216, 95% CI 1.358-3.616 (app) and OR 2.117, 95% CI 1.415-3.168 (televisit). Kind of hospitalization, diagnosis of a chronic disease, disease severity and distance from the health care center were not associated with the outcome variables.

CONCLUSION

Families of pediatric patients with different clinical problems are keen to embark in telemedicine programs, independently from severity of disease or chronicity, and of distance from the hospital.

Next Generation House Call

Just as online shopping is supplanting visits to the mall, and distance learning is part of the new wave in higher education, so is health care coming to a computer or mobile device near you. In the next few years, telehealth will increasingly become part of psychiatric and neurological care. Still to overcome is an unwieldy health care system that will need to adapt to practices that have the potential to lower costs and improve care.

Development of a prehospital vital signs chart sharing system

OBJECTIVE

Physiological parameters are crucial for the caring of trauma patients. There is a significant loss of prehospital vital signs data of patients during handover between prehospital and in-hospital teams. Effective strategies for reducing the loss remain a challenging research area. We tested whether the newly developed electronic automated prehospital vital signs chart sharing system would increase the amount of prehospital vital signs data shared with a remote trauma center prior to hospital arrival.

METHODS

Fifty trauma patients, transferred to a level I trauma center in Japan, were studied. The primary outcome variable was the number of prehospital vital signs shared with the trauma center prior to hospital arrival.

RESULTS

The prehospital vital signs chart sharing system significantly increased the number of prehospital vital signs, including blood pressure, heart rate, and oxygen saturation, shared with the in-hospital team at a remote trauma center prior to patient arrival at the hospital (P < .0001). There were significant differences in prehospital vital signs during ambulance transfer between patients who had severe bleeding and non-severe bleeding within 24 hours after injury onset.

CONCLUSIONS

Vital signs data collected during ambulance transfer via patient monitors could be automatically converted to easily visible patient charts and effectively shared with the remote trauma center prior to hospital arrival. The prehospital vital signs chart sharing system increased the number of precise vital signs shared prior to patient arrival at the hospital, which can potentially contribute to better trauma care without increasing labor and reduce information loss during clinical handover.