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Kim J, Olaiya MT, De Silva DA, Norrving B, Bosch J, De Sousa DA, Christensen HK, Ranta A, Donnan GA, Feigin V, Martins S, Schwamm LH, Werring DJ, Howard G, Owolabi M, Pandian J, Mikulik R, Thayabaranathan T, Cadilhac DA. Global stroke statistics 2023: Availability of reperfusion services around the world. Int J Stroke 2024; 19:253-270. [PMID: 37853529 PMCID: PMC10903148 DOI: 10.1177/17474930231210448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed. AIMS To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services. METHODS We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary. RESULTS Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world. CONCLUSION Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Bo Norrving
- Department of Clinical Sciences, Section of Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jackie Bosch
- School of Rehabilitation Science, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Diana A De Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Hanne K Christensen
- Department of Neurology, University of Copenhagen and Bispebjerg Hospital, Copenhagen, Denmark
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, Wellington, New Zealand
| | - Geoffrey A Donnan
- Melbourne Brain Centre, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - George Howard
- Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mayowa Owolabi
- Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Robert Mikulik
- Health Management Institute, Brno, Czech Republic
- Neurology Department, Bata Hospital, Zlin, Czech Republic
| | - Tharshanah Thayabaranathan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
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Yu AYX, Penn J, Austin PC, Lee DS, Porter J, Fang J, Redelmeier DA, Kapral MK. Telemedicine use and outcomes after transient ischemic attack and minor stroke during the COVID-19 pandemic: a population-based cohort study. CMAJ Open 2022; 10:E865-E871. [PMID: 36195342 PMCID: PMC9544239 DOI: 10.9778/cmajo.20220027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has led to an increase in telemedicine use. We compared care and outcomes in patients with transient ischemic attack (TIA) or minor ischemic stroke before and after the widespread adoption of telemedicine in Ontario, Canada, in 2020. METHODS In a population-based cohort study using linked administrative data, we identified patients with TIA or ischemic stroke discharged from any emergency department in Ontario before the widespread use of telemedicine (Apr. 1, 2015, to Mar. 31, 2020) and after (Apr. 1, 2020, to Mar. 31, 2021). We measured care, including visits with a physician, investigations and medication renewal. We compared 90-day death before and after 2020 using Cox proportional hazards models, and we compared 90-day admission using cause-specific hazard models. RESULTS We identified 47 601 patients (49.3% female; median age 73, interquartile range 62-82, yr) with TIA (n = 35 695, 75.0%) or ischemic stroke (n = 11 906, 25.0%). After 2020, 83.1% of patients had 1 or more telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before. The overall access to outpatient visits within 90 days remained unchanged (92.9% before v. 94.0% after; risk difference 1.1, 95% confidence interval [CI] -1.3 to 3.5). Investigations and medication renewals were unchanged. Clinical outcomes were also similar before and after 2020; the adjusted hazard ratio was 0.97 (95% CI 0.91 to 1.04) for 90-day all-cause admission, 1.06 (95% CI 0.94 to 1.20) for stroke admission and 1.07 (95% CI 0.93 to 1.24) for death. INTERPRETATION Care and short-term outcomes after TIA or minor stroke remained stable after the widespread implementation of telemedicine during the COVID-19 pandemic. Our findings suggest that telemedicine is an effective method of health care delivery that can be complementary to in-person care for minor ischemic cerebrovascular events.
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Affiliation(s)
- Amy Y X Yu
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont.
| | - Jeremy Penn
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Peter C Austin
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Douglas S Lee
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Joan Porter
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Jiming Fang
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Donald A Redelmeier
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Moira K Kapral
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
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Appireddy R, Bendahan N, Chaitanya J, Shukla G. Virtual Care for Neurological Practice. Ann Indian Acad Neurol 2021; 23:587-591. [PMID: 33623255 PMCID: PMC7887478 DOI: 10.4103/aian.aian_415_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 11/04/2022] Open
Abstract
The COVID-19 crisis has worsened the pre-existing barriers to accessing neurological specialist care in Low and middle income countries. Telemedicine has been available for well over 2 decades but has not been widely adopted in LMIC's due to issues around cost, feasibility, infrastructure and regulation. Virtual care is an offshoot of traditional telemedicine leveraging the widely available internet enabled devices to connect patients with their healthcare providers. In this manuscript, we provide an overview of the virtual care, relevance to neurology and some guidance on implementing virtual care in an Indian context.
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Affiliation(s)
- Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Nathaniel Bendahan
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jsk Chaitanya
- Consultant Intensivist, Royalcare Super Speciality Hospital, Coimbatore, Tamil Nadu, India
| | - Garima Shukla
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
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Abstract
We reviewed stroke care delivery during the COVID-19 pandemic at our stroke center and provincial telestroke system. We counted referrals to our prevention clinic, code strokes, thrombolysis, endovascular thrombectomies, and activations of a provincial telestroke system from February to April of 2017–2020. In April 2020, there was 28% reduction in prevention clinic referrals, 32% reduction in code strokes, and 26% reduction in telestroke activations compared to prior years. Thrombolysis and endovascular thrombectomy rates remained constant. Fewer patients received stroke services across the spectrum from prevention, acute care to telestroke care in Ontario, Canada, during the COVID-19 pandemic.
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Bladin CF, Kim J, Bagot KL, Vu M, Moloczij N, Denisenko S, Price C, Pompeani N, Arthurson L, Hair C, Rabl J, O'Shea M, Groot P, Bolitho L, Campbell BCV, Dewey HM, Donnan GA, Cadilhac DA. Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust 2020; 212:371-377. [DOI: 10.5694/mja2.50570] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Chris F Bladin
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
- Ambulance Victoria Melbourne VIC
| | - Joosup Kim
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
- Monash Health, Monash University Melbourne VIC
| | - Kathleen L Bagot
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
- Monash Health, Monash University Melbourne VIC
| | | | | | | | | | - Nancy Pompeani
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | | | | | | | | | | | | | - Bruce CV Campbell
- Melbourne Health Melbourne VIC
- Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Melbourne VIC
| | | | - Geoffrey A Donnan
- Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of Melbourne Melbourne VIC
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
- Monash Health, Monash University Melbourne VIC
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Swanson MB, Miller AC, Ward MM, Ullrich F, Merchant KA, Mohr NM. Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort. J Telemed Telecare 2019; 27:343-352. [PMID: 31684801 DOI: 10.1177/1357633x19877746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs. METHODS A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital. RESULTS Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69-5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31-2.50). DISCUSSION Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.
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Affiliation(s)
- Morgan B Swanson
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, Colleges of Medicine and Public Health, University of Iowa, Iowa City, IA, USA
| | - Aspen C Miller
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Kimberly As Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, Colleges of Medicine and Public Health, University of Iowa, Iowa City, IA, USA.,Department of Anesthesia, Division of Critical Care, University of Iowa, Iowa City, IA, USA
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Mohr NM, Young T, Harland KK, Skow B, Wittrock A, Bell A, Ward MM. Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study. Telemed J E Health 2018; 25:93-100. [PMID: 29958087 DOI: 10.1089/tmj.2018.0013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs. INTRODUCTION The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs. MATERIALS AND METHODS This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital. RESULTS Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy. CONCLUSIONS Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.
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Affiliation(s)
- Nicholas M Mohr
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 2 Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 3 Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Tracy Young
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 4 Injury Prevention Research Center, University of Iowa College of Public Health, Iowa City, Iowa
| | - Karisa K Harland
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Brian Skow
- 5 Avera eCARE, Sioux Falls, South Dakota
| | | | | | - Marcia M Ward
- 6 Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
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