TOPLINE:

Evaluation via telemedicine in stroke care, or “telestroke,” enhances access to thrombolysis for acute ischemic stroke but leads to significant treatment delays, with patients 44% less likely to receive guideline-concordant door-to-needle (DTN) times within 60 minutes, a multicenter registry study showed. While improving treatment accessibility, telestroke evaluation was associated with 6.55 minutes longer DTN times and 47 minutes longer door-in-door-out (DIDO) transfer times than standard care.

METHODOLOGY:

• Researchers analyzed 3036 patients with acute ischemic stroke (mean age, 70 years; 51.5% men; 77.5% White individuals) in 42 hospitals from the Paul Coverdell Michigan Stroke Registry between 2022 and 2023.
• Participants potentially eligible for thrombolysis were evaluated either using telestroke (26%) or without it (74%).
• Primary outcomes were administration of thrombolysis and DTN treatment time as both continuous and categorical variables (≤ 60 vs > 60 minutes).
• Secondary outcomes included the occurrence of postthrombolytic symptomatic intracerebral hemorrhage (ICH), in-hospital mortality, discharge modified Rankin Scale (mRS) score, discharge ambulatory status, discharge destination, DTN treatment time, and DIDO time of transferred patients. The outcomes were adjusted for demographics, medical history, and patient and hospital characteristics.

TAKEAWAY:

• Thrombolysis was administered to 55.5% of patients evaluated via telestroke vs 55.0% evaluated without it, with evaluation via telestroke associated with higher odds of receiving thrombolysis (adjusted odds ratio [aOR], 1.61; P = .003) but lower odds of receiving it within 60 minutes (aOR, 0.56; P = .002).
• Patients evaluated by telestroke had delayed treatment with longer DTN (mean difference 6.55 minutes; P = .003) and median DTN (53 vs 46 minutes; P < .001) treatment times as well as a longer median DIDO time (166 vs 150 minutes; P < .001) than those not evaluated by telestroke.
• Fewer patients evaluated by telestroke received guideline-concordant DTN treatment within 60 minutes than those not evaluated by telestroke (60.3% vs 72.3%; P < .001).
• Outcomes including postthrombolytic symptomatic ICH, in-hospital mortality, discharge mRS score, ambulatory status, and discharge destination did not differ significantly between groups after adjustment.

IN PRACTICE:

“Telestroke care has the potential to revolutionize acute stroke treatment by improving access to lifesaving treatment, but our findings highlight clear gaps in the ability to promptly treat these patients after they are evaluated. This is a major opportunity for quality improvement to identify unique factors in telestroke systems that contribute to treatment delays,” the lead author said in a press release.

The authors of an accompanying editorial wrote, “Improvement efforts should address processes at both hub and spoke hospitals. With continued assessment of processes and outcomes across stroke systems of care, and collaboration beyond traditional health system boundaries, we can further improve outcomes for patients treated with telestroke.”

SOURCE:

The study was led by Brian Stamm, MD, clinical assistant professor of neurology at University of Michigan Medical School, Ann Arbor, Michigan. The accompanying editorial was authored by Laura K. Stein, MD, MPH, Icahn School of Medicine, Mount Sinai, New York City, and Kori S. Zachrison, MD, MSc, Mass General Brigham and Harvard Medical School, Boston. The commentary and the study were published online on September 26 in JAMA Network Open.

LIMITATIONS:

The study used a single‑state (Michigan) registry, which may have limited its generalizability to other regions. The telestroke variable had been newly introduced and had substantial missingness and heterogeneity in some clinical and hospital‑level data across sites, which prevented the complete analysis of all measures for the full sample. Functional outcomes were measured at hospital discharge rather than the standard 90‑day follow‑up, and the relatively small number of transferred patients treated with thrombolysis limited statistical power for DIDO analyses and prevented the inclusion of hospital‑level covariates in models. Because the study used an observational design comparing different patients across hospitals, residual confounding may have persisted despite robust adjustments.

DISCLOSURES:

The study was funded by the Michigan Department of Health and Human Services, CDC, and Timely Topics in Telehealth/e-Health Research Seed Funding from the Institute for Healthcare Policy and Innovation at the University of Michigan. Several investigators reported having financial and other ties with various organizations. Details are provided in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.