Telestroke: Long-term risk factor management – part II

Abstract

Summary Background Stroke is a largely preventable acute disease, with a short time window in which damage to the brain can be reduced. Effective long-term risk factor management can reduce the risk of recurrent stroke but secondary prevention measures remain frequently sub-optimally implemented in stroke survivors. Telemedicine and telestroke in particular can deliver important and necessary healthcare services to stroke survivors. Although telemedicine has been utilized mainly in thrombolysis procedures during the acute phase, it can potentially address the remaining stages of the stroke victim's journey following discharge from hospital or the rehabilitation setting. In this article, we will primarily discuss the current data regarding prevention and limitation of acute brain damage resulting from cerebral infarction, but will also consider other growing areas in stroke care where telemedicine has a potential role. This article will therefore examine the use of telestroke in stroke survivors after discharge from hospital, with emphasis on models of care and their applicability. Methods With a base of 22 studies originating from the Canadian Agency for Drugs and Technologies in Health (CADTH) literature review, we further searched the literature for all articles dealing with stroke and telemedicine in stroke survivors. The results were examined via abstracts and if abstracts were unavailable, full-text versions were sighted. Searches were limited to the period from 1998 to 2009 and no restriction was placed on study designs. Databases searched were Medline EMBASE, CINAHL, AMED, PsycInfo and Cochrane. The main subject terms used were telemedicine, telephone, electronic mail, videoconferencing and stroke. Results From the primary sources, we found 82 papers in total, of which 72 were retained for examination. In eight studies, the telemedicine focus was not on rehabilitation and six of these were randomized controlled trials (RCT). Telerehabilitation was the focus of 12 other studies, only one being an RCT. A total of 28 studies evaluated a variety of measures in stroke patients. Of the non-rehabilitation telestroke studies involving stroke survivors, these comprised, for example, Internet education, passive case management, videophone-supported education, and nursing outreach telephone support models, among others. There have been 21 other studies (one RCT) describing the application of telestroke in rehabilitation. Conclusion There is an urgent need, particularly in rural and underserved areas, to develop long-term management systems in stroke survivors that are both integrated and sustainable. In these more remote areas, the implementation of telemedicine may fill the gap in health care provision created by the high demand on healthcare provider time, the critical shortage of professional health services and geographical distance. The long-term management of risk factors in stroke survivors rests with the primary care physician or other health practitioner. Unfortunately, therapeutic inertia is common at primary care level. To address this, a combination of “hub and spoke” case-management model and linear model could be advantageous. Telestroke may also minimise the inappropriate variations in medical practice.