Panorama Telestroke a viable option to improve stroke care in India Padma V. Srivastava1, Paulin Sudhan2, Dheeraj Khurana3, Rohit Bhatia1, Subash Kaul4, P. N. Sylaja5, Majaz Moonis6, and Jeyaraj Durai Pandian7* In India, stroke care services are not well developed. There is a need to explore alternative options to tackle the rising burden of stroke. Telemedicine has been used by the Indian Space Research Organization (ISRO) to meet the needs of remote hospitals in India. The telemedicine network implemented by ISRO in 2001 presently stretches to around 100 hospitals all over the country, with 78 remote/rural/district health centers connected to 22 specialty hospitals in major cities, thus providing treatment to more than 25 000 patients, which includes stroke patients. Telemedicine is currently used in India for diagnosing stroke patients, subtyping stroke as ischemic or hemorrhagic, and treating accordingly. However, a dedicated telestroke system for providing acute stroke care is needed. Keeping in mind India’s flourishing technology sector and leading communication networks, the hub-andspoke model could work out really well in the upcoming years. Until then, simpler alternatives like smartphones, online data transfer, and new mobile applications like WhatsApp could be used. Telestroke facilities could increase the pool of patients eligible for thrombolysis. But this primary aim of telestroke can be achieved in India only if thrombolysis and imaging techniques are made available at all levels of health care. Key words: acute, developing countries, stroke, telemedicine, telestroke, thrombolysis

Stroke burden in India Developing countries like India are facing a dual burden of communicable and noncommunicable diseases. The estimated ageadjusted prevalence rate of stroke ranges between 84–262 per 100 000 population in rural areas and 334–424 per 100 000 in urban areas. According to recent population-based studies, the incidence rate of stroke is estimated to be 119–145 per 100 000 (1). Correspondence: Jeyaraj Durai Pandian*, Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana 141008, India. E-mail: [email protected] 1 Neurology, All India Institute of Medical Sciences, New Delhi, India 2 Neurology, Christian Medical College, Ludhiana, India 3 Neurology, Postgraduate Institute for Medical Education and Research, Chandigarh, India 4 Neurology, Nizam Institute for Medical Sciences, Hyderabad, India 5 Neurology, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India 6 Stroke Services, UMass Memorial Medical Center, Worcester, MA, USA 7 Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, India Received: 8 February 2014; Accepted: 20 May 2014; Published online 18 July 2014 Conflict of interest: The authors have no financial conflicts of interest. DOI: 10.1111/ijs.12326 © 2014 World Stroke Organization

Stroke care services in India The stroke care pathway in developed countries includes rapid patient identification, transport of patients by ambulance to an emergency department, and prompt imaging followed by acute treatment of stroke. Further treatment and rehabilitation measures are provided by stroke care units consisting of trained physicians, nurses, physiotherapists, and other health care personnel. In contrast, stroke care services in developing countries like India are not well developed. Health care in India follows a threetier system: primary health centers at the village level, secondary centers at the taluk (county) level, and tertiary centers, including medical colleges and hospitals, at the district headquarters level (2). Majority of the Indian population lives in rural areas, and with 75% of qualified consultants practicing at urban centers, health care services have become inaccessible and unaffordable. Though the central (federal) and state governments are taking measures to improve ambulance services, there are remote areas not accessible by proper roads, which makes transfer to higherlevel centers very difficult. In addition, 1200 neurologists, available only at the tertiary centers, have to cater to the needs of 1·2 billion people. Also, there is an imbalanced distribution of radiology services, grossly tilted toward urban regions (2). Most patients do not present in the window period due to lack of awareness of the need for early transport and diagnosis. But even if some do arrive within 3 to 4·5 h, thrombolysis is unaffordable for most of them and unavailable in most hospitals, including a few tertiary centers. Hence there is a large vacuum in stroke management, ranging from acute primary care to rehabilitation. Are there any alternative or adjuvant methods by which we could arrive at a solution? Telestroke has the potential for ameliorating these serious and seemingly intractable problems in stroke care delivery, including the uneven geographic distribution of health care resources and the ever-escalating cost of care.

Telemedicine and telestroke in India Telestroke is widely used in the USA and Germany and is being implemented in Australia as well. The number of patients receiving thrombolysis has also increased with the use of telestroke (3–5). Mortality rates and functional outcomes have been found to be similar and comparable for telemedicine-linked community hospitals and stroke centers (3–5). India is taking a lead among developing countries in the field of telemedicine. Telemedicine activities in India began in 1999. The Indian Space Research Organization (ISRO) has been deploying a satellite-based telemedicine network across the country since that year. Beginning with ISRO’s pilot telemedicine project of 2001, Vol 9, October 2014, 133–134

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Panorama the telemedicine network in India presently stretches to around 100 hospitals all over the country, with 78 remote/rural/district hospitals/health centers connected to 22 specialty hospitals located in the major cities, thus providing treatment to more than 25 000 patients, which includes stroke patients. Apollo Telemedicine Networking Foundation was the first to set up a rural telemedicine center, in 1999 in Andhra Pradesh, and now has over 125 peripheral centers. Various government agencies are taking initiatives with the aim to provide quality health care facilities to poorly accessible areas through telemedicine. Currently, telemedicine is used in India for diagnosing stroke patients, subtyping stroke as ischemic or hemorrhagic, and treating accordingly. However, a dedicated telestroke system for providing acute stroke care is needed. In the year 2011, under the Indo-US Science and Technology Forum, a team of stroke neurologists from India were trained in telestroke at the University of Massachusetts, USA. But a new system for providing extensive, uniform, and efficient stroke care is yet to be designed. India’s information technology (IT) sector is booming, with the country being flooded with IT parks and a huge population employed in this field. India’s telecommunications network is the second largest in the world based on the total number of telephone users, with more than half of the mobile phones sold in India in 2012 being smartphones. The country has the world’s third-largest Internet user base, with over 137 million as of June 2012. Major sectors of the Indian telecommunications industry are telephony, Internet, and television broadcasting. Hence, with proper initiative and persuasion, there is a tremendous opportunity for great

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P. V. Srivastava et al. advancements in telestroke. Keeping in mind India’s flourishing technology sector and leading communications network, the hub-and-spoke model could work out really well in the upcoming years. But until this model is widely established in India, smartphones, online data transfer, and new mobile applications like WhatsApp could be simpler alternatives. Images and patients’ information can be immediately sent from remote and rural areas to a dedicated full-time or part-time group of radiologists and neurologists, allowing further management to be done based on their reports and opinions. Telestroke facilities could increase the pool of patients eligible for thrombolysis. However, there will be further challenges in making thrombolysis and imaging techniques available at all three tiers of health care. Only then can the primary aim of telestroke being used to increase the pool of patients eligible for thrombolysis be achieved in India.

References 1 Pandian J, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke 2013; 15:128–34. 2 Holla B, Viswanath B, Neelaveni S, Harish T, Kumar CN, Math SB. Karnataka State Telemedicine Project: utilization pattern, current, and future challenges. Indian J Psychol Med 2013; 35:278–83. 3 Schwab S, Vatankhah B, Kukla C et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology 2007; 69:898–903. 4 Bruno A, Lanning KM, Gross H, Hess DC, Nichols FT, Switzer JA. Timeliness of intravenous thrombolysis via telestroke in Georgia. Stroke 2013; 44:2620–2. 5 Nagao KJ, Koschel A, Haines HM, Bolitho LE, Yan B. Rural Victorian Telestroke Project. Intern Med J 2012; 42:1088–95.

© 2014 World Stroke Organization

Telestroke a viable option to improve stroke care in India.

In India, stroke care services are not well developed. There is a need to explore alternative options to tackle the rising burden of stroke. Telemedic...
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