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Press review
European Research in Telemedicine/La Recherche Européenne en Télémédecine (2013) 2, 29—30
Available online at
www.sciencedirect.com
Press review Revue de presse E. Medeiros de Bustos ∗, D. Chavot , B. Bouamra Service de neurologie, CHU de Besancon Jean-Minjoz, 3, boulevard Fleming, 25030 Besanc¸on cedex, France Received 31 August 2012; accepted 4 October 2012 Available online 7 November 2012
Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study 䊏 Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ et al. Stroke. 2012;43:2086—90, [originally published online June 12, 2012] An increasing number of studies within the rapidly growing field of telestroke are actively contributing to the re-evaluation, rethinking and improvement of telestroke structures, often through novel experiments. This article, by Liman et al. [1], and similar publications [2], is no exception. Citing the usual reasons for delays in thrombolysis for acute ischaemic stroke such as onset to treatment time, and the demonstrated improved outcome through telemedicine technology, the authors aim to develop a means to expedite the prehospital delays. The article thus reports a study focusing on the feasibility of utilising telestroke in the emergency ambulance setting. Via a pilot study, prehospital telestroke assessment by the National Institutes of Health Stroke Scale (NIHSS) was conducted in ambulances with actors simulating stroke symptoms. Three different raters, one hospital-based, one ambulance-based, and one assessing a posteriori, were blinded to the simulated stroke scenario. Feasibility of
∗
Corresponding author. E-mail address: med [email protected] (E. Medeiros de Bustos).
2212-764X/$ — see front matter http://dx.doi.org/10.1016/j.eurtel.2012.10.001
administrating the Stroke Scale, as well as investigation of audio and visual quality and feasibility of the telestroke ambulance were the primary aims. The results demonstrate that forty per cent of the total NIHSS assessments could be completed, for which interrater reliability was deemed moderate between the hospital- and ambulance-based physicians, and good between the ambulance-based physician and the a posteriori physician (weighted kappa values of 0.69 and 0.79 respectively). Audiovisual technical difficulties accounted for the remaining NIHSS assessments that could not be performed. The article also reports that 60 and 87% of the NIHSS items (of the completed assessments) had excellent and good kappa scores respectively, demonstrating excellent reliability. The items with poor reliability scores correspond to NIH items notorious for poor reliability, such as ataxia. Overall, the study was limited by the low percentage of completed NIHSS assessments as well as the use of actors rather than real patients, and did not render the pilot procedure feasible. Furthermore, as the authors point out, such a study is not easily transferable, and the results are not necessarily applicable in other countries or regions. Despite these limitations, the preliminary findings provide a good and solid basis on which to conduct further research. This interesting study should encourage others to overcome the difficulties reported in it, in order to optimise and dynamise telestroke.
30
E. Medeiros de Bustos et al. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs 䊏 Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. Stroke 2012;43:2078—85, [originally published online June 14, 2012]
Due to the relatively new development of telestroke networks, the latter have often developed in isolation to one another, with the (detrimental) result that there has been a lack of communication and sharing of information between networks. This article [3] reports an insightful overview of the current telestroke network in the United States, revealing successes, issues and obstacles that are not too different from the European experience, and which provides a comparison and example of methods of communication. Firstly, the authors aimed to identify telestroke programs, via Internet searches, and then, secondly, to extrapolate from those programs (via a survey) information useful in determining success factors and obstacles to telestroke. They found that 56 programs met their criteria, of which 38 (68%) participated in their research. From these centres, they collated data including the type of network, the reasons for establishing a telestroke network, hospital and patient data, and finally obstacles to network enlargement. Furthermore, detailed information was collected on the organisational elements of the networks, such as the type of imaging, data storage, team composition, and network functioning. Silva et al. report that the main internal motivations for establishing a telestroke network comprise providing community benefit as well as improving clinical outcomes and cost-effectiveness, with other factors such as legislation being influential. A sharp rise in telestroke networks over the study period was also noted, with a fairly short median duration of 2.44 years. Specialist emergency department stroke consultations are supported by all programs, and most use video and teleradiology to facilitate the consultation process. Some pertinent obstacles revealed in the study cannot be transferred to a European context, or if so only partially. Despite being cost-effective in the long-term, telestroke has limited reimbursement in the United States, and until recently rt-PA thrombolysis had not been adequately financed, leading to non-administration of an important and highly effective treatment for acute ischaemic stroke. Moreover, obtaining a license to practice medicine is also fraught, with re-application required when spokes are added to the
network and if they are in another state. This necessarily incurs delays and is a great barrier to the expansion of telestroke networks. As the authors themselves point out, there were significant limitations to the study. Firstly, 32% of the telestroke networks agreed to participate in the survey, resulting in a possible non-response bias. Certain information such as the number of teleconsultations and tele-thrombolysis were unavailable. Moreover, data gathered from telephone interviews is necessarily subjective and therefore biased. Nonetheless, the article reports an interesting study giving a general overview of the majority of U.S. telestroke networks, their organisation, technological differences and common hindrances. Furthermore, there was information particularly valuable to the European telestroke context; the survey itself is incredibly important as it provides a basis on which to create a similar study to assess the telestroke situation in Europe. The sharing of information and data collection as detailed by Silva et al. is a crucial example for those aiming to achieve a comprehensive overview in Europe, of great utility for reducing disparities and cost, improving stroke care and access, and improving outcome for the one million Europeans affected by stroke a year [4]. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements The authors would like to thank Holly Sandu for her help in writing this press review. References [1] Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ, et al. Telestroke ambulances in prehospital stroke management—concept and pilot feasibility study. Stroke 2012;43:2086—90. [2] LaMonte MP, Cullen J, Gagliano DM, Gunawardane R, Hu P, Mackenzie C, et al. TeleBAT: mobile telemedicine for the brain attack team. J Stroke Cerebrovasc Dis 2000;9:128—35. [3] Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs. Stroke 201;43(8):2078—85. [4] European cardiovascular disease statistics. Brussels: European Heart Network; 2008.
Available online at
www.sciencedirect.com
Press review Revue de presse E. Medeiros de Bustos ∗, D. Chavot , B. Bouamra Service de neurologie, CHU de Besancon Jean-Minjoz, 3, boulevard Fleming, 25030 Besanc¸on cedex, France Received 31 August 2012; accepted 4 October 2012 Available online 7 November 2012
Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study 䊏 Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ et al. Stroke. 2012;43:2086—90, [originally published online June 12, 2012] An increasing number of studies within the rapidly growing field of telestroke are actively contributing to the re-evaluation, rethinking and improvement of telestroke structures, often through novel experiments. This article, by Liman et al. [1], and similar publications [2], is no exception. Citing the usual reasons for delays in thrombolysis for acute ischaemic stroke such as onset to treatment time, and the demonstrated improved outcome through telemedicine technology, the authors aim to develop a means to expedite the prehospital delays. The article thus reports a study focusing on the feasibility of utilising telestroke in the emergency ambulance setting. Via a pilot study, prehospital telestroke assessment by the National Institutes of Health Stroke Scale (NIHSS) was conducted in ambulances with actors simulating stroke symptoms. Three different raters, one hospital-based, one ambulance-based, and one assessing a posteriori, were blinded to the simulated stroke scenario. Feasibility of
∗
Corresponding author. E-mail address: med [email protected] (E. Medeiros de Bustos).
2212-764X/$ — see front matter http://dx.doi.org/10.1016/j.eurtel.2012.10.001
administrating the Stroke Scale, as well as investigation of audio and visual quality and feasibility of the telestroke ambulance were the primary aims. The results demonstrate that forty per cent of the total NIHSS assessments could be completed, for which interrater reliability was deemed moderate between the hospital- and ambulance-based physicians, and good between the ambulance-based physician and the a posteriori physician (weighted kappa values of 0.69 and 0.79 respectively). Audiovisual technical difficulties accounted for the remaining NIHSS assessments that could not be performed. The article also reports that 60 and 87% of the NIHSS items (of the completed assessments) had excellent and good kappa scores respectively, demonstrating excellent reliability. The items with poor reliability scores correspond to NIH items notorious for poor reliability, such as ataxia. Overall, the study was limited by the low percentage of completed NIHSS assessments as well as the use of actors rather than real patients, and did not render the pilot procedure feasible. Furthermore, as the authors point out, such a study is not easily transferable, and the results are not necessarily applicable in other countries or regions. Despite these limitations, the preliminary findings provide a good and solid basis on which to conduct further research. This interesting study should encourage others to overcome the difficulties reported in it, in order to optimise and dynamise telestroke.
30
E. Medeiros de Bustos et al. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs 䊏 Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. Stroke 2012;43:2078—85, [originally published online June 14, 2012]
Due to the relatively new development of telestroke networks, the latter have often developed in isolation to one another, with the (detrimental) result that there has been a lack of communication and sharing of information between networks. This article [3] reports an insightful overview of the current telestroke network in the United States, revealing successes, issues and obstacles that are not too different from the European experience, and which provides a comparison and example of methods of communication. Firstly, the authors aimed to identify telestroke programs, via Internet searches, and then, secondly, to extrapolate from those programs (via a survey) information useful in determining success factors and obstacles to telestroke. They found that 56 programs met their criteria, of which 38 (68%) participated in their research. From these centres, they collated data including the type of network, the reasons for establishing a telestroke network, hospital and patient data, and finally obstacles to network enlargement. Furthermore, detailed information was collected on the organisational elements of the networks, such as the type of imaging, data storage, team composition, and network functioning. Silva et al. report that the main internal motivations for establishing a telestroke network comprise providing community benefit as well as improving clinical outcomes and cost-effectiveness, with other factors such as legislation being influential. A sharp rise in telestroke networks over the study period was also noted, with a fairly short median duration of 2.44 years. Specialist emergency department stroke consultations are supported by all programs, and most use video and teleradiology to facilitate the consultation process. Some pertinent obstacles revealed in the study cannot be transferred to a European context, or if so only partially. Despite being cost-effective in the long-term, telestroke has limited reimbursement in the United States, and until recently rt-PA thrombolysis had not been adequately financed, leading to non-administration of an important and highly effective treatment for acute ischaemic stroke. Moreover, obtaining a license to practice medicine is also fraught, with re-application required when spokes are added to the
network and if they are in another state. This necessarily incurs delays and is a great barrier to the expansion of telestroke networks. As the authors themselves point out, there were significant limitations to the study. Firstly, 32% of the telestroke networks agreed to participate in the survey, resulting in a possible non-response bias. Certain information such as the number of teleconsultations and tele-thrombolysis were unavailable. Moreover, data gathered from telephone interviews is necessarily subjective and therefore biased. Nonetheless, the article reports an interesting study giving a general overview of the majority of U.S. telestroke networks, their organisation, technological differences and common hindrances. Furthermore, there was information particularly valuable to the European telestroke context; the survey itself is incredibly important as it provides a basis on which to create a similar study to assess the telestroke situation in Europe. The sharing of information and data collection as detailed by Silva et al. is a crucial example for those aiming to achieve a comprehensive overview in Europe, of great utility for reducing disparities and cost, improving stroke care and access, and improving outcome for the one million Europeans affected by stroke a year [4]. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements The authors would like to thank Holly Sandu for her help in writing this press review. References [1] Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ, et al. Telestroke ambulances in prehospital stroke management—concept and pilot feasibility study. Stroke 2012;43:2086—90. [2] LaMonte MP, Cullen J, Gagliano DM, Gunawardane R, Hu P, Mackenzie C, et al. TeleBAT: mobile telemedicine for the brain attack team. J Stroke Cerebrovasc Dis 2000;9:128—35. [3] Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs. Stroke 201;43(8):2078—85. [4] European cardiovascular disease statistics. Brussels: European Heart Network; 2008.