Two years’ experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke)

Access to specialized health care in rural areas is often restricted due to limited availability and long travelling distances [1, 2]. This holds also true for treatment of acute stroke patients where treatment delays are associated with worse outcome [3‐5]. Approved treatments for acute stroke include intravenous thrombolysis or mechanical revascularization which may improve stroke symptoms. However, these procedures are only effective within a certain time frame [6‐8]. Thus, different efforts have been made to shorten the door-to-needle-time (DTNT) by optimizing in-hospital processes [9, 10]. To reduce the onset-to-door-time (OTDT), however, educational means among the population are needed as well as changes in the pre-hospital admission processes to the nearest qualified hospital. While the first can increase the awareness for stroke signs and for immediate action in the general public, the implementation of telestroke units can reduce the spatial distance to a facility providing help and, thus, avoid time elapsing senselessly [11, 12].

Previous studies from Europe and the United States showed differences between urban and rural regions in terms of stroke incidence as well as management after a cerebrovascular event [13, 14] resulting in a higher stroke mortality in rural regions compared to urban areas [15]. In addition, a lower awareness and recognition of stroke symptoms as well as of stroke risk factors can be found in the rural population [16, 17]. Finally, an insufficient training of paramedics in pre-hospital stroke management and considerable delays in triage of stroke patients as well as diagnostic testing and a lack of experience in intravenous thrombolysis have to be counted among the reasons for urban-rural disparities [18].

In order to address the challenge of minimizing rural/urban differences and providing appropriate health care independent of population density, telemedicine networks were proposed for providing expert support and for bridging long distances by audio-visual means [19, 20]. In terms of stroke care this means a 24/7-service for non-specialised community hospitals provided by hospitals with expertise in stroke care [21]. In Germany, during the last two decades telemedical networks have been established including academic and community hospitals in sparsely-populated regions [21]. While positive impacts have been demonstrated [22, 23], most reports, however, focus on one specific issue, such as the reliable determination of the NIHSS score [24], a timely access to computer tomography [25] or to intravenous thrombolysis [9, 26‐30].

On the basis of a telemedical stroke network comprising all hospitals in north-western Bavaria (Germany), we aimed to evaluate the impact of the network structure on stroke care in a mainly rural area. Over the first 2 years, the development of a set of predefined health care quality indicators covering aspects of diagnostics, therapy and stroke outcome was analysed in detail.

The Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke) was established in October 2014. It covers an area of about 10,500 km² in north-western Bavaria, comprising Lower Franconia and two neighbouring districts with a catchment area of 1.5 million inhabitants (census 12/2017). According to the NUTS3 definition of the European Union, two-thirds of the area are classified as ‘predominantly rural’ [31] with a population density of 97 inhabitant per km².

The TRANSIT-Stroke Network currently comprises a total of 12 hospitals, comprising three levels of expertise in stroke care (status as at 31.03.2019):

With these 12 clinical centres in the network, TRANSIT-Stroke comprises all hospitals offering stroke care within north-western Bavaria and its surroundings. The involvement of all three levels of stroke care is a unique feature within networks located in Germany. A recently published analysis showed, that level-I-hospitals are situated predominantly at the edge of a 30-min-accessibility of level-III-hospitals [35].

Within the network, there is a two-sided interaction between the levels of care. While three of the stroke centres (level III) provide teleconsultations for hospitals of level I and II, the latter can transfer patients requiring specialized care to hospitals of higher levels. In addition, specific training options for personnel in level-I-hospitals are provided by specialized personnel of level-III-hospitals. These included additional teleconsultations focusing on secondary prevention once a month as well as on on-site visits twice a year. Professional face-to-face training courses took place twice a year, at least, in which stroke specific knowledge was taught, such as surveying the NIHSS. During teleconsultations, guidance for conducting intravenous thrombolysis (IVT; dissolving the drug, preparing infusion, administering IVT) was given in case of need step by step. Regarding transferral to another hospital, decision was made by level-III-experts depending on brain image findings, suspected stroke aetiology, and severity of symptoms.. Beside this vertical exchange, there is also a horizontal integration in respect to a lack of specific treatment facilities (i.e., neurosurgery, interventional neuroradiology or intensive care) in level-II/III-hospitals.

Data on quality of acute hospital care are collected within the regional stroke register Bavaria, a member of the German Stroke Registers Study Group (ADSR) [36]. For patients with a transient ischaemic attack (TIA) (ICD-10: G45) or an ischaemic, haemorrhagic or undefined stroke (ICD-10: I61, I63, I64) a predefined set of data was recorded. Data collection encompassed information on the index event as well as on diagnostics, treatment and outcome. In addition, information on co-morbidities and risk factors as well as on complications and discharge were documented. Data collection is mandatory since 2013. Information was recorded digitally by members of the staff at each hospital and transferred electronically to the coordinating centre of the Bavarian Permanent Working Party for Quality Assurance in Munich, Germany. Completeness of data collection is checked electronically, but not monitored with regard to content. Every participating hospital contributed data for internal analyses. For the present study, however, we included only those hospitals, which were actively involved in the network and delivered data for the whole study period (i.e., 2015 and 2016). Thus, data of eight hospitals were available for this analysis (three level-I-, two level-II- and three level-III-hospitals). The number of teleconsultations conducted per hospital was recorded on a monthly basis.

In order to measure quality of stroke care, a set of evidence-based quality indicators (QI) was defined covering different aspects of stroke care in the following domains: diagnostics, treatment and outcome [36]. These indicators were developed by the multidisciplinary quality indicator board of the German Stroke Register Study group within a standardized process comprising a literature review, a standardized consensus procedure, an external evaluation and a pilot study [36]. The set of quality indicator is updated regularly. For the present analysis, the following QIs covering different processes of stroke care were analysed [23] using their target values of 2016 (see also Table 2): Brain imaging (CT or MRI) within 60 min after admission, vascular imaging (ultrasonography, CT-angiography or MR-angiography) within 48 h after admission, intravenous thrombolysis in patients aged 18–80 years with symptom onset within 4 h and an NIHSS score of ≤25 points, treatment with platelet inhibitor ≤48 h after onset in patients aged ≥18 years, treatment with platelet inhibitor at discharge in patients aged ≥18 years, atrial fibrillation screening in stroke patients without known AF, dysphagia screening within 2 days after admission, mobilization within 2 days after admission, physiotherapy within 2 days after admission, speech therapy within 2 days after admission, rehabilitation assessment in handicapped stroke patients, antihypertensive drug prescription in hypertensive patients, prescription of statins at discharge, door-to-needle-time, and revascularisation of symptomatic carotid stenosis (definition of each single item is provided in the online supplement (see additional file 1)). Target values indicating good quality of care were defined by the quality indicator board of the German Stroke Register Study group.

Statistical analyses were stratified for levels of hospitals (level-I- vs. level-II/III-hospitals). Data are presented as absolute and relative frequencies as well as mean ± standard deviation (SD) or – where appropriate – as median and interquartile range (IQR). For each QI the percentage of patients fulfilling it was calculated quarterly and put in relation to the respective predefined threshold. Time trends in performance for quarters of 2 years were investigated with (asymptotic) Cochrane-Armitage-Test. The level of significance was set to alpha = 0.05. All analyses were performed using SAS 9.4.

The TRANSIT-Stroke network and data acquisition has been approved by the Ethic Committee of the University of Würzburg (54/14) and was registered in the German Registry for Clinical Studies (DRKS: No. 11696). The data presented were collected for the purpose of quality assurance and, thus, the identity of the individual patients were anonymous. Therefore, no specific informed consent on individual level was obtained by the patients.

Patients assigned to level-I-hospitals were slightly older compared to those assigned to level-II/III-hospitals. This is in line with other studies evaluating urban-rural differences in stroke care [37‐39]. However, there are also reports on balanced distribution [15, 18] or younger patients in level-I-hospitals [28, 40]. We observed a higher portion of women in level-I-hospitals while in level-II/III-hospitals the distribution was reversed. This opposite direction of the distribution between the sexes has not been observed yet. Though other studies also report different proportions of sexes in different hospital levels, the majority clearly stays with one sex [15, 18, 28, 38, 40].

While patients with ischaemic or haemorrhagic stroke were transferred to specialized clinical centres, i.e. level-II/III-hospitals, patients with TIA (ICD-10: G 45) were more frequently treated in level-I-hospitals. The higher proportion of unspecified strokes (ICD-10: I 64) in level-I-hospitals might point out their missing resources to determine the aetiology of stroke. The difference of diagnoses found in stroke centres and in communal hospitals in TRANSIT-Stroke Network was comparable to that in other studies [18, 37]. Of note, this difference appeared irrespectively whether the analysed hospitals were organised in a network [37] or not [18].

In the observed period, a total of 1542 teleconsultations were performed in interaction with level-I-hospitals, of which 927 (60%) were strokes and TIAs and, thus, 615 (40%) were mimics or other diseases. This share is consistent with – though much higher than – other networks reporting 20% of mimics [25].

While other networks have hubs and spoke, i.e. two levels of hospitals [23, 41, 42], TRANSIT-Stroke involves all three levels currently defined in Germany. Thereby, all these hospitals are integrated in the network and, thus, in telemedical counselling and in regular training courses. Especially these regular training options within TRANSIT-Stroke are thought to be the reason for the improvement of several QIs in level-I-hospitals.

The present study has several strengths: The QIs presented in this analysis cover all sections of in-house treatment and describe stroke care extensively. By including different QIs regarding diagnostics, secondary prevention and cerebrovascular imaging, we were able to increase knowledge about issues which have not been investigated well so far; some QIs were even reported for the first time. We are aware of the following limitations: Our results may be biased due to the limited numbers of patients admitted to level-I-hospitals, representing 12% of the population included in the analysis. This distribution is due to the setting of rather low population density and comparable to other studies investigating urban and rural health care (range from 7 to 16%) [14, 18, 39, 40, 43]. In addition, not all hospitals participating in the network to date were included in the present analysis. Due to reasons of privacy protection in Germany, transferral within the TRANSIT-Stroke Network could not be considered for analyses. The QIs used in this analysis focused on in-house aspects of stroke care. Thus, issues such as awareness of stroke in the population, reduction of onset-to-door-time before and after implementation of the network or quality of stroke rehabilitation stay disregarded. Assessment of treatment safety, e.g., regular monitoring of haemorrhagic complications (asymptomatic/symptomatic intracranial haemorrhages) was not part of this analysis. However, newly defined quality indicators will be included in further studies to improve additionally health care and, thus, for example, will also consider mechanical thrombectomy. Implausibilities at first sight in the descriptive data, such as reported thrombectomies in level-I-hospitals, were not monitored but can be explained by re-transfer after surgery.

With the implementation of the TRANSIT-Stroke Network the range of specialists’ expertise is extended beyond the 30-min-accessibility of level-II- and level-III-hospitals. Thereby, it is delivered towards rural areas without time delay caused by transportation.