The Effect of Telemedicine in IV-tPA Time Metrics of Acute Ischemic Stroke on and After-hours at Medically Underserved versus Non-medically Underserved Areas.

Introduction: Telemedicine (TM) may alleviate disparities in patients with acute ischemic stroke (AIS) in rural or medically underserved areas (MUAs) by increasing access to specialists. AIS metrics may also differ between patients who present to emergency rooms during nonworking hours. We compared time metrics and outcomes of AIS patients who received intravenous tissue plasminogen activator (IV-tPA) via TM during on-hours and after-hours at hospitals in MUAs with those during on-hours and after-hours at hospitals in non-MUAs. Methods: We identified suspected AIS patients who received IV-tPA via TM from 9/2016 - 12/2017. We compared baseline characteristics, time metrics, and outcomes between the after-hours (5pm-7:59am) and on-hours (8am-4:59pm) patients in MUAs and non-MUAs. Wilcoxon rank-sum test, Chi-square test, or Fisher’s exact test were used for two-group comparisons. Results: Of 662 patients evaluated via TM, 297 were seen during on-hours, and 365 after-hours; with 462 patients seen at non-MUA sites and 200 at MUA sites. There were no significant differences in baseline characteristics aside from racial demographics (Table 1). There was no difference in door-to-needle-time between all groups, in spite of small differences of door to CT (non-MUA sites were 5 minutes longer after hours than MUA sites, p=0.002) and onset to door time (MUA being 10 minutes longer on hours than non-MUA, p=0.027). Outcomes were slightly poorer for MUA compared to non-MUA, including discharge disposition (home: 53.9% vs 63.7%, p=0.004) and modified Rankin Scale (mRS≥4: 43% vs 27%, p=0.001). Conclusions: TM can provide AIS patients at spoke hospitals with 24/7 access to stroke specialists and standard of care evaluation and treatment. Lack of resources in MUA could be the reason for poorer outcomes however further research is needed.