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Telemedicine Versus Telephone for Remote Emergency Stroke Consultations: A Critically Appraised Topic

Capampangan, Dan J. MD*; Wellik, Kay E. MLS, AHIP†; Bobrow, Bentley J. MD‡§; Aguilar, Maria I. MD¶; Ingall, Timothy J. MD, PhD¶; Kiernan, Terri-Ellen NP¶; Wingerchuk, Dean M. MD, MSc, FRCP(C)*; Demaerschalk, Bart M. MD, MSc, FRCP(C)¶

doi: 10.1097/NRL.0b013e3181a4b79c
Critically Appraised Topics

Background: The rate of patients being treated with thrombolytic therapy is low, in part, due to a shortage of vascular neurologists, especially in rural communities. Two-way audio-video communication through telemedicine has been demonstrated to be a reliable method to assess neurologic deficits due to stroke and maybe more efficacious in determining thrombolytic therapy eligibility than telephone-only consultation.

Objective: To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations.

Methods: The objective was addressed through the development of a structured, critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the fields of vascular neurology, emergency medicine, and telemedicine. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed a critical appraisal, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions.

Results: A single randomized, blinded, prospective trial comparing telephone-only consultations to telemedicine consultations for acute stroke was selected and appraised. Correct acute stroke treatment decisions were made more often in the telemedicine group versus the telephone-only group (98% vs. 82%, [number needed to assess = 6]). Stroke telemedicine when compared with telephone-only consultations was more sensitive (100% vs. 58%), more specific (98% vs. 92%), had a more favorable positive likelihood ratio (LR: 41 vs. 7) and negative likelihood ratio (LR: 0 vs. 0.5), and had higher predictive values (positive predictive value 94% vs. 76%, and negative predictive value 100% vs. 84%) for the determination of thrombolysis eligibility.

Conclusion: Stroke telemedicine when compared with telephone-only consultations is an effective method to determine thrombolysis eligibility for acute stroke patients who do not have immediate access to a stroke neurologist.

From the *Department of Neurology, the †Library Services, Division of Educations Services, and the ‡Department of Emergency Medicine, Mayo Clinic Arizona, Scottsdale, Arizona; §Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona; and ¶Division of Cerebrovascular Diseases, Department of Neurology, Mayo Clinic Arizona, Scottsdale, Arizona.

Supported by Mayo Clinic College of Medicine Clinician Educator Grants (to B.M.D., D.M.W., Codirectors, Mayo Clinic Evidence Based Clinical Practice, Research, Informatics, and Training [MERIT] Center); and STRokE DOC Arizona TIME trial (ClinicalTrials.gov NCT00623350) and the STARR trial (ClinicalTrials.gov NCT00829361) (to B.M.D., B.J.B., M.I.A., T.J.I., T.E.K.) in the Arizona Department of Health Services.

Reprints: Bart M. Demaerschalk, MD, MSc, FRCP(C), Department of Neurology, Cerebrovascular Diseases Center, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 13400 East Shea Bld., Scottsdale, Arizona 85259. E-mail: Demaerschalk.bart@mayo.edu.

© 2009 Lippincott Williams & Wilkins, Inc.