An article published early online and in the September issue of Lancet
Neurology compares telemedicine with telephone consultations
for treatment in remote locations. Dr Brett C. Meyer
(University of California San Diego School of Medicine Stroke Center,
USA) and colleagues report that more accurate decisions are made in the
important 3-hour window following stroke if physicians use
telemedicine, not telephones, when treating victims who live outside of
large cities.
Telemedicine incorporates real-time, two-way audio and video as well as
digital imaging and communications. Meyer and colleagues conducted a
prospective study in order to determine whether telemedicine or
telephone communication would result in better decision-making outcomes
during consultations in remote areas. The sample included 222 patients,
older than 18 years, who from January 2004 to January 2007 presented at
one of four remote sites in California. The patients were randomly
assigned so that 111 received a telemedicine consultation and 111
received a telephone consultation for assessing their readiness for
thrombolytic drug treatment. Effective treatment using thrombolytic
drugs after stroke requires the expertise of skilled vascular
neurologists. A stringent, multi-level central judging authority
determined whether the decisions made by the remote physicians to give
or not to give the drugs were correct or not.
The results of the study supported telemedicine as superior to
telephone consultations. In 98% of telemedicine consultations and in
82% of telephone consultations, physicians made correct treatment
decisions. Though more patients in the telemedicine group received
thrombolytics than in the telephone group (31% vs. 25%), the difference
was not statistically significant. In addition, the researchers found
no statistical difference in rates of stroke recurrence or death. These
results could, however, be a function of the small sample size or the
fact that the study was halted and telephone consultations ceased
because of the clear superiority of telemedicine in making treatment
decisions.
"The results of this trial show that telemedicine is efficacious for
making acute medical decisions. Stroke telemedicine is widely
implemented and discussed, 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," conclude the authors.
Dr Pierre Amarenco (Clinical Research in Atherothrombosis and Denis
Diderot University, Bichat Stroke Centre, Paris, France) writes in an
accompanying comment that in high-income countries, there is a massive
difference in treatment received by people living in big cities and
people in rural areas. "The next step is to show that telethrombolysis
is equivalent to or better than the gold standard treatment to improve
the percentage of patients with no handicap at three months. This would
represent top level evidence for using and developing telemedicine for
equal and improved access to alteplase in all patients with stroke.
Such a study is currently recruiting patients in France...In the
meantime, the study by Meyer and colleagues reinforces that
telethrombolysis should be strongly preferred to telephone
consultation," concludes Dr. Amarenco.
Efficacy of site-independent telemedicine in the STRokE DOC
trial: a randomised, blinded, prospective study
Brett C Meyer, Rema Raman, Thomas Hemmen, Richard Obler,
Justin A Zivin, Ramesh Rao, Ronald G Thomas, Patrick D Lyden
The Lancet Neurology (2008).
DOI:10.1016/S1474-4422(08)70171-6
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: Peter M Crosta