Kori Sauser-Zachrison1, Ernest Shen2, Navdeep Sangha3, Zahra Ajani4, William P Neil5, Michael K Gould6, Dustin Ballard7, Adam L Sharp8. 1. Assistant Professor in the Department of Emergency Medicine at Massachusetts General Hospital and Harvard Medical School in Boston. ksauser@mgh.harvard.edu. 2. Biostatistician in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. ernest.shen@kp.org. 3. Neurologist at the Los Angeles Medical Center in CA. navdeep.x.sangha@kp.org. 4. Neurologist at the Los Angeles Medical Center in CA. zahra.a.ajani@kp.org. 5. Neurologist at the San Diego Medical Center in CA. william.p.neil@kp.org. 6. Research Scientist in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. michael.k.gould@kp.org. 7. Emergency Physician at the San Rafael Medical Center in CA. dustin.ballard@kp.org. 8. Physician in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. adam.l.sharp@kp.org.
Abstract
CONTEXT: There is substantial hospital-level variation in use of tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Telestroke services can bring neurologic expertise to hospitals with fewer resources. OBJECTIVE: To determine whether implementation of a telestroke intervention in a large integrated health system would lead to increased tPA utilization and would change rates of hemorrhagic complications. DESIGN: A stepped-wedge cluster randomized trial of 11 community hospitals connected to 2 tertiary care centers via telestroke, implemented at each hospital incrementally during a 1-year period. We examined pre- and postimplementation data from July 2013 through January 2015. A 2-level mixed-effects logistic regression model accounted for the staggered rollout. MAIN OUTCOME MEASURES: Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications. RESULTS: Of the 2657 patients, demographic and clinical characteristics were similar in pre- and postintervention cohorts. Utilization of tPA increased from 6.3% before the intervention to 10.9% after the intervention, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients (odds ratio = 2.0; 95% confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of the 10 were at least as likely to administer tPA as the highest-volume center. CONCLUSION: Telestroke implementation in a regional integrated health system was safe and effective. Community hospitals' rates of tPA utilization quickly increased and were similar to the largest-volume tertiary care center.
RCT Entities:
CONTEXT: There is substantial hospital-level variation in use of tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Telestroke services can bring neurologic expertise to hospitals with fewer resources. OBJECTIVE: To determine whether implementation of a telestroke intervention in a large integrated health system would lead to increased tPA utilization and would change rates of hemorrhagic complications. DESIGN: A stepped-wedge cluster randomized trial of 11 community hospitals connected to 2 tertiary care centers via telestroke, implemented at each hospital incrementally during a 1-year period. We examined pre- and postimplementation data from July 2013 through January 2015. A 2-level mixed-effects logistic regression model accounted for the staggered rollout. MAIN OUTCOME MEASURES: Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications. RESULTS: Of the 2657 patients, demographic and clinical characteristics were similar in pre- and postintervention cohorts. Utilization of tPA increased from 6.3% before the intervention to 10.9% after the intervention, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients (odds ratio = 2.0; 95% confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of the 10 were at least as likely to administer tPA as the highest-volume center. CONCLUSION: Telestroke implementation in a regional integrated health system was safe and effective. Community hospitals' rates of tPA utilization quickly increased and were similar to the largest-volume tertiary care center.
Authors: I L Katzan; A J Furlan; L E Lloyd; J I Frank; D L Harper; J A Hinchey; J P Hammel; A Qu; C A Sila Journal: JAMA Date: 2000-03-01 Impact factor: 56.272
Authors: Devin L Brown; William G Barsan; Lynda D Lisabeth; Michael E Gallery; Lewis B Morgenstern Journal: Ann Emerg Med Date: 2005-07 Impact factor: 5.721
Authors: Lee H Schwamm; Heinrich J Audebert; Pierre Amarenco; Neale R Chumbler; Michael R Frankel; Mary G George; Philip B Gorelick; Katie B Horton; Markku Kaste; Daniel T Lackland; Steven R Levine; Brett C Meyer; Philip M Meyers; Victor Patterson; Steven K Stranne; Christopher J White Journal: Stroke Date: 2009-05-07 Impact factor: 7.914
Authors: Bart M Demaerschalk; Sravanthi Vegunta; Bert B Vargas; Qing Wu; Dwight D Channer; Joseph G Hentz Journal: Stroke Date: 2012-11-15 Impact factor: 7.914
Authors: Lee H Schwamm; Eric S Rosenthal; Alan Hirshberg; Pamela W Schaefer; Elizabeth A Little; Joseph C Kvedar; Iva Petkovska; Walter J Koroshetz; Steven R Levine Journal: Acad Emerg Med Date: 2004-11 Impact factor: 3.451
Authors: Sam Wang; Sung Bae Lee; Carol Pardue; Davinder Ramsingh; Jennifer Waller; Hartmut Gross; Fenwick T Nichols; David C Hess; Robert J Adams Journal: Stroke Date: 2003-09-18 Impact factor: 7.914
Authors: Kori Sauser-Zachrison; Ernest Shen; Zahra Ajani; William P Neil; Navdeep Sangha; Michael K Gould; Adam L Sharp Journal: Perm J Date: 2016-03-25
Authors: Sam Wang; Hartmut Gross; Sung Bae Lee; Carol Pardue; Jennifer Waller; Fenwick T Nichols; Robert J Adams; David C Hess Journal: Stroke Date: 2004-05-27 Impact factor: 7.914
Authors: Arianna Moreno; Lee H Schwamm; Khawja A Siddiqui; Anand Viswanathan; Cynthia Whitney; Natalia Rost; Kori Sauser Zachrison Journal: Telemed J E Health Date: 2017-12-22 Impact factor: 3.536
Authors: Richa Sharma; Kori S Zachrison; Anand Viswanathan; Marcelo Matiello; Juan Estrada; Christopher D Anderson; Mark Etherton; Scott Silverman; Natalia S Rost; Steven K Feske; Lee H Schwamm Journal: Circ Cardiovasc Qual Outcomes Date: 2020-03-04
Authors: Kori S Zachrison; Emily M Hayden; Krislyn M Boggs; Tehnaz P Boyle; Jingya Gao; Margaret E Samuels-Kalow; James P Marcin; Carlos A Camargo Journal: J Med Internet Res Date: 2022-06-20 Impact factor: 7.076
Authors: Kori S Zachrison; Krislyn M Boggs; Emily M Hayden; Rebecca E Cash; Janice A Espinola; Margaret E Samuels-Kalow; Ashley F Sullivan; Ateev Mehrotra; Carlos A Camargo Journal: J Am Coll Emerg Physicians Open Date: 2020-09-01
Authors: Kori S Zachrison; Jessica V Richard; Andrew Wilcock; Jose R Zubizarreta; Lee H Schwamm; Lori Uscher-Pines; Ateev Mehrotra Journal: JAMA Netw Open Date: 2021-09-01
Authors: Sushma K Gurav; Kapil G Zirpe; R S Wadia; Avinash Naniwadekar; Prajakta U Pote; Amit Tungenwar; Abhijeet M Deshmukh; Srikanta Mohopatra; Balakrishna Nimavat; Prasad Surywanshi Journal: Indian J Crit Care Med Date: 2018-04