Saturday 16 May 2009

New AHA/ASA Guidelines on TIA Management and Telemedicine in Acute Stroke Released

May 8, 2009 — The American Heart Association (AHA)/American Stroke Association (ASA) has released 2 new guideline documents, 1 advocating urgent treatment for transient ischemic attacks (TIA) and changing the clinical definition and the other giving a green light to the use of telemedicine consults in acute stroke assessment.

Along with the 2 scientific statements, a policy statement has also been published to provide recommendations on how best to implement telemedicine in stroke care systems.

The TIA and telemedicine stroke documents are published online May 7 and will appear in the June and July issues of Stroke, respectively.

New Definition of TIA

In the scientific statement examining the definition and evaluation of TIAs, the writing group points out that large cohort and population-based studies reported in the past 5 years have shown that the risk for stroke after a TIA is higher than previously thought. "Ten percent to 15% of patients have a stroke within 3 months, with half occurring within 48 hours," the group, chaired by J. Donald Easton, MD, professor and chair of the department of clinical neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital, in Providence, writes.

Accordingly, the authors recommend that TIAs be subject to the same urgent assessment and care given to acute strokes and, to that end, have changed the clinical definition of TIA. "We think a TIA should be treated as an emergency, just like a major stroke," Dr. Easton said in a news release from the AHA/ASA. "Because we know the high risk for a future stroke, this is a golden opportunity to prevent a catastrophic event."

The traditional clinical definition, dating to the mid-1960s, is "a sudden neurological deficit of presumed vascular origin lasting less than 24 hours." The new statement changes this definition to "a transient episode of neurological dysfunction caused by focal brain, spinal-cord, or retinal ischemia, without acute infarction."

The presence of infarction has been the main distinction between stroke and TIA, but the advent of more sensitive imaging of tissue damage using magnetic resonance imaging (MRI) has suggested that infarction with presumed TIAs may occur often.

"Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI," Dr. Easton noted.

Long-Distance Stroke Assessment

In the scientific statement on telemedicine, the writing group, chaired by Lee Schwamm, MD, from Harvard Medical School and Massachusetts General Hospital, in Boston, provides an evidence-based review of the scientific evidence supporting the use of telemedicine for stroke care delivery and concludes that high-quality videoconferencing systems can be used by remote stroke specialists to carry out National Institutes of Health Stroke Scale (NIHSS)-telestroke examinations when a bedside assessment is not immediately available for patients who may be having an acute stroke and provide results comparable to the beside assessment.

It is recommended that these examinations be supported by the use of a Food and Drug Administration (FDA)–approved teleradiology system, where computed-tomography (CT) and MRI scans can also be viewed by the remote stroke specialist, the authors note. The specialist can then make recommendations to the on-site providers about whether tissue plasminogen activator should be used or not.

Similarly, these systems can be used to provide occupational and physical therapy remotely, the document notes.

"Telemedicine is an effective avenue to eliminate disparities in access to acute stroke care, erasing the inequities introduced by geography, income, or social circumstance," Dr. Schwamm said in news release from the AHA/ASA.

Changes in reimbursement for telemedicine activities, though, are required for implementation of a telestroke system and require consideration of a number of other issues, including cost recovery, liability, and training of provider. For that reason, a second document of policy recommendations accompanies the scientific statement.

The recommendations include:

* Whenever local or on-site acute stroke expertise or resources are insufficient to provide around-the-clock coverage for a healthcare facility, telestroke systems should be deployed to supplement resources at participating sites.
* New models and codes for reimbursement of telestroke services should be developed to reflect the increased up-front costs to providers and reduced long-term healthcare costs to insurers.
* Organizations providing or requesting telemedicine services should operate by contractual agreements that explicitly deal with such issues as assignment of costs for developing and maintaining the telemedicine network; compliance with relevant federal, state, and local statute boundaries and any existing noncompete relationships; assessment of medicolegal risk and provision of adequate malpractice coverage; and administrative and credentialing requirements for all providers.

"Telestroke can enable the initiation of cost-effective interventions proven to reduce complications and stroke recurrence and can identify and facilitate transfer of patients in the community for specific tertiary-care interventions, such as neurointensive care, decompressive surgery for life-threatening, space-occupying cerebral infarction, and prompt surgical or endovascular repair of ruptured cerebral aneurysms," the authors conclude.

Dr. Easton reports he has served as a consultant/advisory board member for Boehringer Ingelheim and Sanofi-Aventis. Disclosures for the coauthors on the TIA statement appear in the paper. Dr. Schwamm reports he has served as a consultant/advisory board member for the Massachusetts Department of Public Health, CoAxia, CryoCath, RTF, and Phreesia but has no commercial activities related to telemedicine. Disclosures for coauthors for the telemedicine statement appear in the paper.

Source : http://www.medscape.com/viewarticle/702546?src=mpnews&spon=34&uac=133298AG

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