Specialized Care and Telemedicine Improve Stroke Outcomes

By Crystal Phend
BERLIN, 23 nov 2008-- The long-term prognosis for stroke patients is better at community hospitals equipped with monitoring technology, trained multidisciplinary teams, and teleconsultation capability, researchers found.
Hospitals that implemented such stroke unit treatment in the Bavaria region of Germany significantly reduced combined death, institutional care, and disability among stroke patients by 35% at 12 months (P<0.01) and by 18% at 30 months (P=0.031) compared with other community hospitals, said Heinrich J. Audebert, M.D., of Charite Hospital here, and colleagues.
In the prospective study, the change also tended to reduce the rate of death and institutional care at 12 months (odds ratio 0.89, P=0.23) and 30 months (OR 0.93, P=0.40) after adjustment for potential confounders, the researchers reported online in Stroke: Journal of the American Heart Association.
"The set-up of stroke wards in community hospitals with appropriate facilities and education supported by telemedicine-linked academic stroke centers offers a new way to provide specialized stroke care in smaller hospitals," the researchers concluded.
Their Telemedical Project for Integrative Stroke Care (TEMPiS) compared five hospitals that implemented the stroke intervention with another five general community hospitals in the same in region but without specialized stroke services or telemedical networking.
The intervention included establishing stroke wards with multidisciplinary stroke teams trained through continuing medical education and monitoring facilities, developing standardized treatment protocols at the centers, and providing a 24-hour teleconsultation service through two academic stroke centers.
The researchers had previously shown three-month survival and dependency advantages at hospitals that made these changes and joined the telemedicine network.
To see what the long-term effects were, the researchers studied outcomes for the 3,060 consecutive patients with ischemic or hemorrhagic stroke admitted from July 2003 through March 2005 after the stroke care system was set up.
After about two and a half years of patient follow-up, cumulative survival rates were 68.0% in the intervention group compared with 65.5% in the control group (P=0.271).
In multivariate analysis, implementation of the stroke ward and telemedicine changes significantly reduced the rate of "death and dependency" -- the combined rate of death, institutional care, and disability measured as a score of more than 60 on the Barthel index or a Rankin score above 3 -- at 12 months (OR 0.65, P<0.01) and 30 months (OR 0.82, P=0.031).
The intervention appeared to have its greatest effect early after stroke. The two hospital groups had the largest absolute difference in this outcome at three months (10.4% versus 9.3% at 12 months and 5.2% at 30 months).
The impact of the intervention may have been offset by an increasing impact of other factors such as age and other diseases with time, Dr. Audebert and colleagues said.
After adjustment for potential confounders, the intervention did not significantly reduce the combined rate of death and institutional care at 12 months (OR 0.89, P=0.23) and 30 months (OR 0.93, P=0.40) compared with typical community hospital care.
The researchers attributed the lack of significance to smaller absolute differences, which the study was "clearly underpowered to detect."
Nevertheless, they said, the reduction in the likelihood of overall death or dependency at all three follow-up time points and after adjustment suggested "a long-lasting beneficial effect of specialized acute stroke care in community hospitals with continuous medical education and telemedicine consultation."
They cautioned that the effect of the changes implemented at the community hospitals could not be attributed to telemedicine consultation alone because only 36% of admitted stroke patients at these hospitals had a teleconsult.
They pointed out that "in contrast to randomized, controlled trials that balance all observed and unobserved confounders between treatment and control groups, we cannot rule out that some unobserved differences in patient characteristics between the intervention group and the control group contributed to our results."
As an example, they noted that the intervention might have changed the characteristics of patients admitted to these hospitals because stroke patients in some areas were preferentially sent to intervention hospitals expecting better care.
The analysis was funded by the German Federal Ministry of Research within the Competence Net Stroke.
The intervention study was supported as a pilot project by the Bavarian Health Insurance Companies and has become part of regular stroke care with ongoing reimbursement. The study was partially funded by the Bavarian State Ministry for Employment and Social Order, Family, and Women and the German Stroke Foundation. Boehringer Ingelheim Pharma dispensed stroke lysis boxes in intervention hospitals at the start of the project.
Dr. Audebert reported receiving speaker fees from Meytec, distributor of the telemedicine devices. A coauthor reported being a member of an advisory board of Boehringer Ingelheim Pharma.
Primary source: Stroke: Journal of the American Heart AssociationSource reference:Audebert HJ, et al "Long-Term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS)" Stroke 2009; 40.