Stroke Telemedicine for Arizona Rural Residents, the Legacy Telestroke Study

Bart M Demaerschalk, Maria I Aguilar, Timothy J Ingall, David W Dodick, Bert B Vargas, Dwight D Channer, Erica L Boyd, Terri E J Kiernan, Dennis G Fitz-Patrick, J Gregory Collins, Joseph G Hentz, Brie N Noble, Qing Wu, Karina Brazdys, Bentley J Bobrow, Bart M Demaerschalk, Maria I Aguilar, Timothy J Ingall, David W Dodick, Bert B Vargas, Dwight D Channer, Erica L Boyd, Terri E J Kiernan, Dennis G Fitz-Patrick, J Gregory Collins, Joseph G Hentz, Brie N Noble, Qing Wu, Karina Brazdys, Bentley J Bobrow

Abstract

Background: Efficacy of telemedicine for stroke was first established by the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trials in California and Arizona. Following these randomized controlled trials, the Stroke Telemedicine for Arizona Rural Residents (STARR) network was the first telestroke network to be established in Arizona. It consisted of a 7 spoke 1 hub telestroke system, and it was designed to serve rural, remote, or neurologically underserved communities.

Objective: The objective of STARR was to establish a multicenter state-wide telestroke research network to determine the feasibility of prospective collection, recording, and regularly analysis of telestroke patient consultations and care data for the purposes of establishing quality measures, improvement, and benchmarking against other national and international telestroke programs.

Methods: The STARR trial was open to enrollment for 29 months from 2008 to 2011. Mayo Clinic Hospital, Phoenix, Arizona served as the hub primary stroke center and its vascular neurologists provided emergency telestroke consultations to seven participating rural, remote, or underserved spoke community hospitals in Arizona. Eligibility criteria for activation of a telestroke alert and study enrollment were established. Consecutive patients exhibiting symptoms and signs of acute stroke within a 12 h window were enrolled, assessed, and treated by telemedicine. The state government sponsor, Arizona Department of Health Services' research grant covered the cost of acquisition, maintenance, and service of the selected telemedicine equipment as well as the professional telestroke services provided. The study deployed multiple telemedicine video cart systems, picture archive and communications systems software, and call management solutions. The STARR protocol was reviewed and approved by Mayo Clinic IRB, which served as the central IRB of record for all the participating hospitals, and the trial was registered at ClinicalTrials.gov.

Results: The telestroke hotline was activated 537 times, and ultimately 443 subjects met criteria and consented to participate. The STARR successfully established a multicenter state-wide telestroke research network. The STARR developed a feasible and pragmatic approach to the prospective collection, storage, and analysis of telestroke patient consultations and care data for the purposes of establishing quality measures and tracking improvement. STARR benchmarked well against other national and international telestroke programs. STARR helped set the foundation for multiple regional and state telestroke networks and ultimately evolved into a national telestroke network.

Conclusions: Multiple small and rurally located community hospitals and health systems can successfully collaborate with a more centrally located larger hospital center through telemedicine technologies to develop a coordinated approach to the assessment, diagnosis, and emergency treatment of patients manifesting symptoms and signs of an acute stroke syndrome. This model may serve well the needs of patients presenting with other time-sensitive medical emergencies.Clinical Trial Registration number: NCT00829361.

Keywords: alteplase; digital health; stroke; telemedicine; telestroke; thrombolysis.

Conflict of interest statement

No competing financial interests exist.

© Bart M. Demaerschalk et al., 2022; Published by Mary Ann Liebert, Inc.

Figures

FIG. 1.
FIG. 1.
STARR trial subject enrollment to follow-up flow chart. STARR, Stroke Telemedicine for Arizona Rural Residents.

References

    1. Meyer BC, Raman R, Hemmen T, et al. . Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomized, blinded, prospective study. Lancet Neurol 2008;7:787–795.
    1. Demaerschalk BM, Bobrow BJ, Raman R, et al. . Stroke Team Remote Evaluation Using a Digital Observation Camera in Arizona: the initial Mayo Clinic experience trial. Stroke 2010;41:1251–1258.
    1. Demaerschalk BM, Raman R, Ernstrom K, et al. . Efficacy of telemedicine for stroke: pooled analysis of the Stroke Team Remote Evaluation using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemed J E Health 2012;18:230–237.
    1. Miley ML, Demaerschalk BM, Olmstead NL, et al. . The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine. Telemed J E Health 2009;15:691–699.
    1. Demaerschalk BM, Miley ML, Kiernan TE, et al. . Stroke telemedicine. Mayo Clin Proc 2009;84:53–64.
    1. Jauch ED, Saver JL, Adams HP, et al. . Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870–947.
    1. Demaerschalk BM, Kiernan TEJ, STARR Investigators. Vascular neurology nurse practitioner provision of telemedicine consultations. Int J Telemed Appl 2010;2010:507071.
    1. Kiernan TEJ, Demaerschalk BM. Nursing roles within a stroke telemedicine network. J Cent Nerv Syst Dis 2010;2:1–7.
    1. Sairanen T, Soinila S, Nikkanen M, et al. . Two years Finnish Telestroke: thrombolysis at spokes equal to that at the hub. Neurology 2011;76:1145–1152.
    1. Hargreaves JJ, Cabral KM, Demaerschalk BM, et al. . ResolutionMD mobile: delivering advanced visualization and interactive video to wireless devices for acute telemedicine. WH’10: Wireless Health 2010; October 5–7, 2010; San Diego, CA. Conference Proceedings Pages 202–203. Available at Accessed January 13, 2022.
    1. Demaerschalk BM, Bobrow BJ, Raman R, et al. . CT interpretation in a telestroke network: agreement among a spoke radiologist, hub vacular neurologist, and hub neuroradiologist. Stroke 2012;43:3095–3097.
    1. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. . Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2017;48:e3–e25.
    1. Cadilhac DA, Bagot KL, Demaerschalk BM. Establishment of an internationally agreed minimum data set for acute telestroke. J Telemed Telecare 2021;27:582–589.
    1. Kreofsky BL, Blegen RN, Lokken TG, et al. . Sustainable telemedicine: designing and building infrastructure to support a comprehensive telemedicine practice. Telemed J E Health 2018;24:1021–1025.
    1. Lokken TG, Blegen RN, Hoff MD, et al. . Overview for implementation of telemedicine services in a large integrated multispecialty health care system. Telemed J E Health 2020;26:382–387.
    1. Rogove HJ, Amoateng B, Binner J, et al. . A survey and review of telemedicine license portability. Telemed J E Health 2015;21:374–381.
    1. Demaerschalk BM, Berg J, Chong BW, et al. . American Telemedicine Association: telestroke guidelines. Telemed J E Health 2017;23:376–389.
    1. Tipton PW, D'Souza CE, Greenway MRF, et al. . Incorporation of telestroke into neurology residency training: “time is brain and education.” Telemed J E Health 2020;26:1035–1042.
    1. Kramer NM, Demaerschalk BM. A novel application of teleneurology: robotic telepresence in supervision of neurology trainees. Telemed J E Health 2014;20:1087–1092.
    1. Demaerschalk BM, Hwang H-M, Leung G. Cost analysis review of stroke centers, telestroke, and rt-PA. Am J Manag Care 2010;16:537–544.
    1. Nelson RE, Saltzman GM, Skalabrin EJ, et al. . The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology 2011;77:1590–1598.
    1. Switzer JA, Demaerschalk BM, Xie J, et al. . Cost-effectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke from hospitals' perspectives. Circ Cardiovasc Qual Outcomes 2013;6:18–26.
    1. Demaerschalk BM, Switzer JA, Xie J, et al. . Cost utility of hub-and-spoke telestroke networks from societal perspective. Am J Manag Care 2013;19:976–985.
    1. English SW, Barrett KM, Freeman WD, et al. . Telemedicine-enabled ambulances and mobile stroke units for prehospital stroke management. J Telemed Telecare [Epub ahead of print]; 1357633X211047744.
    1. Vargas BB, Channer DD, Dodick DW, et al. . Teleconcussion: an innovate approach to screening, diagnosis, and management of mild traumatic brain injury. Telemed J E Health 2012;18:803–806.
    1. Freeman WD, Barrett KM, Vatz KA, et al. . Future neurohospitalist: teleneurohospitalist. Neurohospitalist 2012;2:132–143.
    1. Rubin MN, Wellik KE, Channer DD, et al. . Systematic review of teleneurology: methodology. Front Neurol 2012;3:156.
    1. Wechsler LR, Tsao JW, Levine SR, et al. . Teleneurology applications: report of the telemedicine work group of the American Academy of Neurology. Neurology 2013;80:670–676.
    1. Rubin MN, Wellik KE, Channer DD, et al. . Systematic review of teleneurology: neurohospitalist neurology. Neurohospitalist 2013;3:120–124.
    1. Demaerschalk BM, Levine SR. Telestroke: solid support for virtual acute stroke care. Neurology 2016;87:1314–1315.
    1. Russi CS, Heaton HA, Demaerschalk BM. Emergency medicine telehealth for COVID-19: minimize front-line provider exposure and conserve personal protective equipment. Mayo Clin Proc 2020;95:2065–2068.
    1. Fang JL, Umoren R, Whyte H, et al. . Provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology. Am J Perinatol 2021. [Epub ahead of print]; DOI: 10.1055/s-0041-1736587.
    1. Meyer JD, McKean AJS, Blegen RN, et al. . Emergency department telepsychiatry service model for a rural regional health system: the first steps. Telemed J E Health 2019;25:18–24.
    1. Rubin MN, Wellik KE, Channer DD, et al. . Role of telemedicine in providing tertiary neurological care. Curr Treat Options Neurol 2013;15:567–582.
    1. Rubin MN, Barrett KM, Freeman WD, et al. . Teleneurosonology: a novel application of transcranial and carotid ultrasound. J Stroke Cerebrovasc Dis 2015;24:562–565.
    1. Guzik AK, Martin-Schild S, Tadi P, et al. . Telestroke across the continuum of care: lessons from the COVID-19 pandemic. J Stroke Cerebrovasc Dis 2021;30:105802.
    1. Rubin MN, Wellik KE, Channer DD, et al. . Systematic review of telestroke for post-stroke care and rehabilitation. Curr Atheroscler Rep 2013;15:343.
    1. Demaerschalk BM, Blegen RN, Ommen SR. Scalability of telemedicine services in a large integrated multidisciplinary health care system during COVID-19. Telemed J E Health 2021;27:96–98.
    1. Huang JF, Greenway MR, Nasr DM, et al. . Telestroke in the time of COVID-19: the Mayo Clinic experience. Mayo Clin Proc 2020;95:1704–1708.
    1. Haddad TC, Blegen RN, Prigge JE, et al. . A scalable framework for telehealth: the Mayo Clinic Center for Connected Care response to the COVID-19 pandemic. Telemed Rep 2021;3:78–87.

Source: PubMed

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