RESEARCH/Original article

Efficacy of telemedicine for thrombolytic therapy in acute ischemic stroke: a meta-analysis

Journal of Telemedicine and Telecare 2015, Vol. 21(3) 123–130 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15571357 jtt.sagepub.com

Yun-kai Zhai1,2,3, Wei-jun Zhu1,4, Hong-li Hou2,3, Dong-xu Sun1,2,4 and Jie Zhao1,2,4

Summary The aim of this study was to assess the benefits of telemedicine in the delivery of thrombolytic therapy for patients with acute ischemic stroke. We performed a meta-analysis using combinations of the following terms: telestroke, telemedicine, tissue plasminogen activator/t-PA, and acute ischemic stroke. The primary outcome was favorable outcome based on the modified Rankin score. Secondary outcomes were incidence of symptomatic intracranial hemorrhage and overall mortality. We found no significant difference in favorable outcome between the telemedicine and control groups, and no significant difference was found between these groups in the rate of symptomatic intracranial hemorrhage or overall mortality. Patients with acute ischemic stroke who were treated with intravenous thrombolysis had similar outcomes regardless of whether telemedicine was used or they were treated in-person at a medical facility. Telemedicine can be used to support hospitals with limited experience in administering thrombolytic therapy for stroke. Keywords telemedicine, stroke, thrombolytic therapy, meta-analysis Accepted: 6 November 2014

Introduction Stroke ranks third among the leading causes of death in Europe, Japan, the United States, and Canada, and ranks first among the leading causes of acquired long-term disability in North America and Europe.1,2 Four-fifths of strokes are attributable to ischemic stroke and one-fifth to hemorrhagic stroke.1 Functional outcomes of stroke patients have been shown to improve when they are treated with the thrombolytic agent alteplase within 3 hours of stroke onset.2,3 However, only a small percentage of patients receive this treatment. For example, in the United States the percentage of stroke patients treated with thrombolytic therapy is only 3.7%.3 A particularly important reason why so few stroke patients receive thrombolytic treatment is that they live in areas where stroke unit care is not available such as in rural areas.2,4 Also, even in urban areas with stroke units available the stroke team may be notified later than the recommended time.5 Telemedicine, or telestroke, has been used as a way to improve treatment for stroke patients who live in areas without adequate treatment facilities.6 Patients are usually examined by video, and brain scans are evaluated by teleradiology.7 Telestroke can be considered as a set of tools for providing improved care for stroke in areas lacking

sufficient neurologic services.8 Although telestroke has been found to improve care, implementing a telestroke network can be challenging.3 A number of studies have found that telestroke increases the rate of administering thrombolytic therapy and improves functional outcomes in acute stroke patients, although none of these studies were randomized controlled trials.2 The aim of this meta-analysis was to evaluate the benefits of telestroke for acute ischemic stroke patients versus in-person care at a medical facility with regard to the delivery of thrombolytic therapy.

1 The first Affiliated Hospital, Zhengzhou University, Zhengzhou, People’s Republic of China 2 Henan Engineering Research Center of Digital Medicine, Zhengzhou, People’s Republic of China 3 Management Engineering School, Zhengzhou University, Zhengzhou, People’s Republic of China 4 Henan Engineering Laboratory for Digital Telemedicine Service, Zhengzhou, People’s Republic of China

Corresponding author: Jie Zhao, The first Affiliated Hospital, Zhengzhou University, Zhengzhou, No.1, East Jianshe Road, Zhengzhou 450052, People’s Republic of China. Email: [email protected]

Downloaded from jtt.sagepub.com at UNIVERSITE LAVAL on May 10, 2015

124

Journal of Telemedicine and Telecare 21(3)

Data extraction

Methods Search strategy During April 2014 the following databases were searched: PubMed, Cochrane, Embase, ISI Web of Knowledge, and ClinicalTrial.gov. There was no specific starting date. The search was conducted using combinations of the following search terms: (telestroke OR telemedicine OR telemedical) AND acute ischemic stroke. In the PubMed search the filters used were Abstract available, English, and Human; in the Embase search the filters used were Article and Human; and in the ISI Web of Knowledge search the filters used were English and Article. The search was carried out by two independent reviews and a third reviewer was consulted to resolve any disagreements. Five studies were randomly selected in order to perform recoding by a different investigator to assess coder drift.9 A determination was made of per case agreement. This was achieved by division using the of the number of variables coded as the numerator and the total number of variables as the denominator. An appropriate level of reliability was deemed to be a mean agreement of 0.90. The coding process was determined to be reliable as coder drift was found to be 0.96.

Selection of studies The studies for inclusion in the meta-analysis were selected based on the following criteria: 1) randomized controlled trials, and prospective and retrospective studies with a two-arm design; 2) patients diagnosed with acute ischemic stroke; and 3) studies compared telemedicine vs. in-person care at a medical facility for delivery of thrombolysis. Cohort studies, letters, comments, editorials, case reports, proceedings, and personal communications were excluded. Studies were also excluded if patients had other types of ischemic stroke or had stroke related to chronic diseases, the study used a singlearm design, there was no quantitative measurement, or the study was published in a language other than English.

Study quality assessment Prospective studies were assessed with the Cochrane ‘‘assessing risk of bias’’ table.10 There are six domains—random sequence generation, allocation concealment, blinding of patients and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting risk. These criteria were taken from the Cochrane Collaboration guidelines. Retrospective studies were assessed with the NewcastleOttawa Scale.11 This scale contains eight items categorized into three dimensions: selection, comparability, and exposure. A star system is used for a semi-quantitative assessment of study quality.

The following types of data were extracted: first author and year study was published, study design, comparison (telemedicine vs control), type of intervention, number of patients, mean age of patients, percentage of male patients, National Institutes of Health Stroke Scale (NIHSS) score at baseline, percentage of patients with a favorable outcome based on modified Rankin score, percentage of patients with symptomatic intracranial hemorrhage, overall mortality rate, and time from stroke onset to treatment. Two independent reviewers extracted the data from eligible studies. A third reviewer was consulted to resolve any disagreements.

Data analysis The primary outcome in the meta-analysis was favorable outcome (modified Rankin score) and the secondary outcomes were incidence of symptomatic intracranial hemorrhage and overall mortality. The odds ratios (ORs) were calculated for the three outcomes in the telemedicine group compared with the control group. Heterogeneity among the studies was assessed by the Cochran Q statistic and the I2 statistic. For the Q statistic, P < 0.10 was considered statistically significant for heterogeneity; for the I2 statistic, which indicated the percentage of the observed between-study variability due to heterogeneity rather than to chance, the suggested ranges were as follows: no heterogeneity (I2 ¼ 0–25%), moderate heterogeneity (I2 ¼ 25– 50%), large heterogeneity (I2 ¼ 50–75%), and extreme heterogeneity (I2 ¼ 75–100%). If either the Q statistic (P < 0.1) or I2 statistic (>50%) indicated heterogeneity existed between studies, the random-effects model was preferred (DerSimonian–Laird method). Otherwise, the fixed-effect model (Mantel-Haenszel method) was recommended. Pooled OR of the outcome was calculated, and a 2-sided P-value

Efficacy of telemedicine for thrombolytic therapy in acute ischemic stroke: a meta-analysis.

The aim of this study was to assess the benefits of telemedicine in the delivery of thrombolytic therapy for patients with acute ischemic stroke. We p...
382KB Sizes 0 Downloads 7 Views