Fast track — ArticlesEfficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study
Introduction
Few patients with stroke (2–3%) receive thrombolytics, although the therapy has been approved for more than 10 years.1 Thrombolytic therapy must be used rapidly and appropriately if stroke disability is to be reduced.2 Previous approaches to increase the rates of treatment have failed, partially because of incomplete dissemination of stroke expertise regarding thrombolytic use and geographical restrictions. Greater availability of stroke specialists should increase the use of appropriate treatments and minimise protocol violations.3, 4 Telemedicine, which has already been implemented in many specialties, could enable the dissemination of stroke expertise for consultation, education, and research.5, 6, 7, 8
Telemedicine is a reliable way to measure deficits due to stroke.9, 10, 11, 12 Remote assistance by telephone13 or telemedicine increases the use of thrombolytics,14, 15, 16 but although many telemedicine systems are available, few randomised trials have been done,17 and the efficacy of decision making is unknown. To assess the correctness of decision making in the time-pressured setting of acute stroke, we compared telemedicine (remote audio or video and radiological review) with telephone consultations, to test the hypothesis that telemedicine increases the efficacy of decision making. If telemedicine decisions are appropriate, this technology can be immediately implemented in daily practice.
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Patients
Between January, 2004, and August, 2007, 234 patients were enrolled and 222 were randomly assigned to telemedicine or telephone-only consultations when they presented with symptoms of acute stroke at one of four remote sites (spokes) that were located 30 to 350 miles from an academic hub. 11 run-in patients were not randomised. Inclusion criteria were age at least 18 years, ability to sign consent (or have a surrogate sign for them), and symptoms of acute stroke. There were no specific
Results
234 patients with symptoms of acute stroke were assessed—eleven non-randomised participants were assessed during the run-in phase—and 222 patients were randomised (figure 1). There were no demographic differences between groups. 90-day outcomes were available for 218 (93%) patients. The risk factors coronary artery disease (p=0·026), hyperlipidaemia (p=0·003), family history of stroke or transient ischaemic attack (TIA; p=0·0002), current alcohol use (p<0·0001), and current tobacco use
Discussion
The results of this prospective, blinded, randomised trial show that telemedicine is efficacious for making acute medical decisions. Stroke telemedicine is widely implemented and discussed,8, 14, 18, 20, 21, 22, 23 but despite its dissemination, its efficacy has not previously been shown. Our results support the use of telemedicine to make urgent treatment decisions, such as whether to use thrombolytic therapy for acute stroke.
Current rates of thrombolytic use are low and could be increased;1,
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