According to the Centers for Disease Control and Prevention, stroke is the leading cause of long-term disability for Americans. When it comes to minimizing the effects of stroke, timely, quality care is crucial. Yet, most stroke centers and specialists are concentrated in major cities, leaving care gaps in many rural communities.

Over the last decade, telestroke networks have been established across the U.S. to address this issue by connecting resource-strapped facilities with neurology specialists in stroke centers. But, do telestroke services help rural patients?

Now, research from the University of Georgia is seeking to answer that question.

Advanced technology by itself does not necessarily result in better care, says Donglan Zhang, an assistant professor of health policy and management at UGA’s College of Public Health.

Zhang recently published two studies both looking at whether telestroke services improved quality of stroke care.

The first, a study appearing in the December issue of Health Affairs, analyzed seven years of Medicare claims to learn what treatment patients received and how they fared in the weeks following their stroke.

Zhang found a correlation between the expansion of telestroke services nationwide with an improvement in quality of care in very rural communities.

“When we look at the national level, we observed a significant improvement in quality of care in both urban and rural counties, and we also observed a reduction in mortality outcome in very rural communities, with a modest increase in cost,” said Zhang.

Her second study focused on a Georgia-based telestroke program, named Remote Evaluation for Acute Ischemic Stroke (REACH). A cut-and-dry improvement in patient care in Georgia is less clear. Zhang and her co-authors found that death rates decreased, but they didn’t find significant improvements in other quality of care indicators. For example, they didn’t find that program participants were using more tissue plasminogen activator, or tPA.

tPA is used to break down blood clots that occur during stroke, preventing further damage to the brain and other organs. An increased use of tPA usually suggests an improvement in care. Yet, patients were surviving more often.

“It seems there isn’t a causal link, but what changed during the process that leads to a favorable outcome in mortality?” said Zhang.

She posits that medical staff at rural hospitals may have picked up some indirect training in stroke assessment simply by participating in the telestroke service network, and her analysis of another less common indicator – complications associated with tPA treatment – support the idea.

Zhang found a modest reduction in the rate of complications associated with tPA among the hospitals participating in a telestroke network.

“Participating in the program could increase the probability of accurately assessing a patient’s eligibility for tPA,” said Zhang. “You cannot give tPA to everyone who comes to the ER. There are exclusion criteria – if a patient arrives too late, is age 80 older, or has had a stroke before. These increase the risk of hemorrhage.”

The nuanced findings presented in Zhang’s national and Georgia-based studies illustrate that the current adoption of telestroke and other telehealth models may not be a silver bullet to improving health outcomes in resource-poor areas of the U.S.

“We assessed the impact of telestroke based on three outcomes – access to care, quality of care and medical cost. We can say telestroke did improve access to critical stroke care particularly for rural patients,” she said. “This is for sure.”

But in terms of quality, she says, more work needs to be done to understand how other quality indicators, such as the time it takes to treat patients after they walk through the door, are performing. In addition, comprehensive economic evaluations are still needed, too.

“Such analysis provides critical evidence to inform payers and health care systems as they consider reimbursing and adopting telehealth models,” said Zhang.

The study on Georgia’ telestroke program, “Impact of Participation in a Telestroke Network on Clinical Outcomes: 25 Evidence from the Georgia Coverdell Acute Stroke Registry” published in the January issue of Circulation Quality of Care and Outcomes. It is available online here.

Additional coverage via ASPPH Friday Letter.

– Lauren Baggett

Posted on January 7, 2019.