How Telehealth Can Help Stroke Patients in Rural Hospitals

A new study from the University of Georgia has investigated the reasons why stroke patients treated in rural hospitals have more negative outcomes and a higher risk of death.

Using data from the 2016 National Inpatient Sample, the study specifically looked at stroke patients who sought treatment in rural hospitals. The researchers identified several factors they believe contributed to the patients' poor outcomes, including the “weekend effect” and lack of resources. They also found that patients who had had a hemorrhagic stroke had particularly poor outcomes.

The findings highlighted the need for telemedicine and "telestroke" programs, which is one way to narrow resource and stroke specialist care gaps in rural communities.

Rural Hospitals

Rural health facilities are often understaffed and not equipped to handle certain acute emergencies. This is especially true on weekends when the quality of care often decreases.

To combat the gaps in care and quality, some facilities are joining telehealthcare networks that allow specialists to access a patient virtually at the bedside via video, review scans in real-time, collaborate with emergency room staff, and recommend a treatment plan. In some cases, that could mean arranging for a life-flight helicopter to transport a patient to a certified hospital with an experienced critical care team.

“Disparity is increased in rural areas.” Christina Mijalski Sells, MD, MPH, Stanford telestroke program medical director, tells Verywell. “[Patients in these areas] may have more baseline risks because of socioeconomic status and a decrease in resources. Telestroke can help reduce those risks.”

What Is a Stroke?

A stroke is a medical emergency that occurs when blood flow and oxygen to the brain are blocked by a clot or a ruptured blood vessel. If not quickly recognized and treated, strokes can lead to permanent damage—if not death.

The American Stroke Association (ASA) lists stroke as the number five cause of death in the United States, but says that 80% of strokes are preventable. If a stroke is immediately diagnosed and treated, a person's odds of surviving and recovering are better than if these interventions are delayed.

There are two types of strokes. The classification depends on the cause of the blockage. The most common types of strokes are:

• Ischemic Stroke: This type of stroke is caused by a clot in a blood vessel blocking blood flow to the brain. It is the most common type of stroke, accounting for 87% of all stroke patients. The treatment goal is to bust or remove the clot and restore blood flow to the brain.
• Hemorrhagic Stroke: This type of stroke is caused by a ruptured blood vessel within the brain. It's not as common as an ischemic stroke, but it is more serious and can be deadly. The treatment goal is to stop the bleeding.

In some cases, the cause of a stroke is not known. This is referred to as a cryptogenic stroke.

Telestroke and Telemedicine

Telemedicine has been around for decades, but recent improvements in technology have allowed for expansion—particularly in the area of telestroke care.

One example is the Stanford Telestroke and Acute Teleneurology Program, which was launched by Stanford Medicine in 2017. The program was intended to expand Stanford's comprehensive stroke center expertise through partnering with hospitals in Northern and Central California. 

Through a formal partner contract with hospitals, the multidisciplinary program can provide 24/7 expert on-call stroke specialists, staff training, and specific protocols. It also gives providers access to the InTouch Vici “robot," which lets stroke specialists use video and audio to communicate with doctors and patients, as well as to share pertinent health information instantaneously. This lets teams work together to create a treatment plan and ensure the continuation of care for patients.

Increase in Telemedicine

Although telehealth technology is not new, the COVID-19 pandemic has increased the need for physicians to be able to treat their patients from a distance as we try to slow the spread of the disease and avoid draining hospital resources.

The Center for Disease Control and Prevention (CDC) states that new pandemic policy changes have paved the way for telehealth to deliver acute, chronic, primary, and specialty care. Many professional medical societies now endorse telehealth and are providing guidance to clinicians on implementing the technology.

“The COVID-19 pandemic has had tremendous and multiple impacts on our healthcare system.” Donglan Zhang, PhD, co-author of the stroke outcomes study and assistant professor at the University of Georgia's College of Public Health, tells Verywell. “Immediately after the COVID-19 outbreak, many healthcare systems experienced a rapid transition from in-person visits to virtual telehealth visits, which shifts the demand of care to telehealth through virtual face-to-face meetings using smartphones, tablets, or webcam-enabled computers.”

As with many facets of health care, some aspects of telehealth make it difficult to reach certain populations. There are also cultural and technological barriers. In some cases, the technology is not well-suited to a case because there is sensitive information involved or it does not allow a clinician to perform an adequate physical assessment. 

Despite these setbacks, Sells says that telehealth is here to stay.

"We are able to see a lot of patients this way," she says. "It is a great alternative for those that can’t travel [a] long distance to our medical center.”

Stroke Risk Factors to Discuss During a Telehealth Visit

A majority of strokes are preventable. Certain health conditions and lifestyle habits can increase your chances of having a stroke. The ASA outlines the most common risk factors, many of which are related to lifestyle factors that you might be able to change.

• Atrial fibrillation: Quivering in the heart’s upper chambers can let blood pool and clot. If a clot breaks off, enters the bloodstream, and lodges in an artery leading to the brain, it can cause a stroke.
• Cigarette smoking: The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk.
• Diabetes mellitus: Many people with diabetes also have high blood pressure, high blood cholesterol, and are overweight. Together, these factors increase their stroke risk. Though diabetes is treatable, the presence of the disease still increases your risk of having a stroke.
• High blood cholesterol: Low HDL (“good”) cholesterol is a risk factor for stroke in men, but more data is needed to see if the effect also occurs in women.
• High blood pressure (hypertension): The number one cause of stroke and the most important controllable risk factor for stroke. More than 20% of those with HBP are unaware of their condition.
• Poor diet: Diets that are high in saturated fat, trans fat, and cholesterol can raise blood cholesterol levels. A high-sodium (salt) diet can contribute to increased blood pressure. Consuming excess calories can contribute to obesity. Following a diet that includes five or more servings of fruits and vegetables per day may reduce stroke risk.
• Physical inactivity and obesity:Inactivity and obesity can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease, and stroke. Try to get a total of at least 30 minutes of activity on most or all days of the week.

Timely Stroke Treatment

To increase the chance of survival and limit long-term effects, the ASA states that an ischemic stroke patient has up to 4.5 hours from the onset of symptoms to receive an intravenous treatment of recombinant tissue plasminogen activator (r-tPA), which works to bust or remove the clot.

In some stroke patients, r-tPA can be used in combination with mechanical thrombectomy, which physically removes the clot using a wire-cage device called a stent retriever. The procedure should be done within six hours of onset of symptoms, but might be beneficial up to 24 hours after symptom onset.

Treatment for a hemorrhagic stroke—which is usually caused by uncontrolled hypertension (high blood pressure)— can include surgery or an endovascular catheter to prevent further rupture.

Whichever treatment is used, time is the number one factor in successful stroke treatment. Telestroke can put a patient in front of a stroke specialist who can coordinate immediate treatment and increase the patient’s chance of survival.