Thrombolytic Imaging-to-Needle Time as a Metric for Comparing Telemedicine versus In-Person Evaluation in Acute Ischemic Stroke.

Abstract

Objectives: Door-to-needle time (DTN) is standard for measuring the efficiency of thrombolytic administration in acute ischemic stroke, with guidelines recommending DTN <60 minutes. DTN can be divided into door-to-imaging time (DIT) and imaging-to-needle time (ITN), separated by arrival at the CT scanner. We hypothesize that ITN is more accurate for comparing the mode of evaluation for stroke patients treated with thrombolytics.

Methods: This is a retrospective cohort study of stroke patients treated with thrombolytics at Southern Illinois Health care. Data on demographics, clinical presentation, stroke metrics, thrombolytic complications, and mRS at 1-month were reviewed. Multivariate logistic regression models were applied to evaluate predictors of DTN, ITN, and DIT, with OR and 95% CI. P-value was set at 0.05.

Results: Out of 287 patients, 170 were evaluated by telemedicine, 117 in-person. The 2 groups were comparable in demographics and stroke severity. Telemedicine had longer median DTN, in minutes [55 (43 to 70) vs. 42 (34 to 62), P<0.01], and median ITN, in minutes [43 (35-58) vs. 32 (25-48), P<0.01]. There was no statistical difference in DIT between the 2 groups. Adjusted for stroke severity and age, telemedicine was associated with lower odds of DTN <60 minutes (OR: 0.553, 95% CI: 0.328-0.931, P=0.026) and ITN <35 minutes (OR: 0.265, 95% CI: 0.159-0.441, P<0.01). However, telemedicine was not independently associated with DIT <25 minutes, which was instead inversely correlated with age (OR: 0.974, 95% CI: 0.951-0.997, P=0.03).

Conclusions: ITN represents a more accurate metric for comparing telemedicine and in-person evaluations than DTN, as it excludes stroke-specific processes of care and patient-specific factors that are intrinsic to DTN and unrelated to the modality of evaluation.