Abstract 273: Diagnostic Accuracy at a Distance: a Quality of Care Assessment of Telestroke in the Intermountain West

Abstract

Objective: Little is known about the quality of care telestroke services provide beyond the accuracy of tPA decision-making in stroke patients. The effect of telestroke on stroke mimics in particular remains relatively unexplored, though telestroke systems have up to a 50% mimic rate. Methods: This was a retrospective review of telestroke consults provided by 8 providers at University of Utah Hospital (the “hub”) to 15 telestroke sites in Utah, Idaho, Wyoming, and Nevada (the “spokes”) from Jan-Oct 2013. We obtained records from the spokes and compared them to those from the hub, including: telestroke and final discharge diagnoses, if IV-tPA was given, and if a patient was transferred. Final diagnosis was based on the hub or spoke site discharge summary, depending on transfer. We calculated a kappa to determine agreement between telestroke and final discharge diagnoses. Results: 73 telestroke cases were reviewed: 9 had a telestroke diagnosis but no final diagnosis; 5 had a final diagnosis but no telestroke diagnosis; 5 had a final diagnosis that differed from the initial telestroke diagnosis (Table). Two received IV-tPA for stroke mimics; no IV-tPA candidates were denied treatment due to inaccurate diagnosis via telestroke. There were no differences in the telestroke vs the final diagnosis in cases not transferred. Kappa was good (0.69) when including the unknown diagnoses and excellent (0.91) when excluding those with poor documentation. Transfer rates were highest in patients initially diagnosed with stroke and lowest for migraine and unmasking of previous stroke. Conclusion: This study is one of the few to examine the accuracy of neurological diagnosis and the effects on transfer in a telestroke system. Telestroke consultants had a high degree of accuracy, particularly for stroke - the purpose of the telestroke network. Accurate diagnoses of non-critical disorders such as migraine allowed such patients to stay at the spoke hospital, reducing unnecessary transfers. These diagnoses were not later found to be inaccurate by the spoke hospital, suggesting such transfer reductions are appropriate. Though improved documentation would help improve our understanding of our system, overall our telestroke service provides accurate neurological diagnoses in the Intermountain West.