Stroke patients have significantly better chances of surviving and living independently when they receive specialized stroke care in community hospitals that have telecommunication support from major stroke centers, according to a study in Stroke: Journal of the American Heart Association.

At 12 and 30 months after stroke, patients treated at hospitals with specialized stroke units had a significantly lower rate of "death and dependency" than did patients who received care at hospitals without stroke units. Dependency was defined as disability or need for institutional care.

The findings extend the benefits of specialized stroke care with telemedicine support initially observed three months after stroke.

"What we see is that not only does the quality of care improve very significantly, but also the subsequent prognosis of the patients," said Heinrich Audebert, M.D., a stroke specialist at Charite Hospital in Berlin, Germany. "These effects are also quite stable. We can see the effects after one and two years and, at least in our trial, after two and a half years."

Most community hospitals don't have dedicated stroke units because of a shortage of experienced physicians and lack of access to stroke-related clinical expertise at major medical centers. Rural areas, in particular, often have inadequate resources to provide specialized stroke care.

The advent of telemedicine has provided an opportunity to expand the reach of specialized acute care services to virtually any hospital, regardless of location. Telemedicine involves using communication links to transmit and receive data and information at remote locations.

In the Telemedical Project for Integrative Stroke Care (TEMPiS), researchers examined the feasibility and potential value of extending specialized stroke care to a large area of the Bavarian region of southeastern Germany. TEMPiS represented a collaboration between two academic stroke centers and community hospitals in Bavaria. Key components of the program included:

• Establishing stroke units at the community hospitals, including forming multidisciplinary stroke teams to provide care;
• Installing monitoring equipment and facilities;
• Training and educating members of the stroke team, including continuous bedside teaching by specialist physicians, nurses and therapists;
• Implementing standard treatment protocols; and
• Twenty-four-hour telemedicine consultation provided by the academic stroke centers.

Researchers compared outcomes among stroke patients treated at five TEMPiS hospitals with patient outcomes at five non-TEMPiS hospitals in the same geographic region. The study included 3,060 stroke patients, 1,938 treated at TEMPiS hospitals and 1,122 treated at other hospitals. Initial results showed that specialized stroke care with telemedicine support led to better outcomes at three months, specifically a significantly lower rate of the composite endpoint of death and dependency.

The improvement was associated with practices indicative of high-quality stroke care: rapid brain imaging, the frequency with which patients received clot-dissolving drugs, assessment of stroke-related swallowing disorders, and early initiation of stroke rehabilitation.

Audebert and colleagues reported on participants for 12 months and 30 months. Consistent with the three-month results, longer follow-up showed a statistically not significant trend towards a better outcome of the combined outcome of death and institutional care.

However, patients treated at the TEMPiS hospitals had a statistically significant 35 percent lower probability of death and dependency at 12 months and almost a 20 percent reduced probability for this poor outcome at 30 months compared with non-TEMPiS patients.

Audebert said a hospital would have to invest about $130,000 (confirmed by author) to set up a specialized stroke unit, including construction and equipment costs. There are also additional costs for augmented nursing and therapist staff in the community hospitals and personal costs for quality management and teleconsultation service in the Stroke Centers. However, these costs are obviously recouped over time by savings related to shorter hospitalizations and less disability.

Co-authors of the article are Kathrin Schultes, M.D.; Viola Tietz, M.D., Roman Habert, M.D.; Johannes Schenkel, M.D.; Peter Heuschmann, M.D.; and Ulrich Bogdahn, M.D.

The German Federal Ministry of Research funded the study.