HOUSTON – October 26, 2015 – Few medical crises are as time sensitive and life-altering as stroke. Clots break away from arteries and travel rapidly to the brain, disrupting blood flow and killing brain cells at a rate of 1.9 million per minute. Death and disability can quickly result.
Fortunately, quick medical intervention results in better health outcomes for acute stroke victims, and this is true regardless of age, sex, socio-economic status, or race. Last year, stroke fell from the 4th leading cause of death in the United States to the 5th, and researchers believe this reduction in mortality reflects both increased awareness of stroke and improved access to advanced stroke treatments.
Access to expert stroke care is not equal, however, and sometimes simple geography is the culprit, especially in a state as vast as Texas. Population densities vary radically across Texas’ 254 counties, and this reality influences where stroke patients are transported for treatment and, consequently, which interventions they receive.
Stroke patients who live in metropolitan areas are usually transported to Primary and Comprehensive Stroke Centers (PSCs and CSCs) where experienced neurologists can diagnose the patient with sophisticated imaging such as MRI. Patients in these areas are more likely to administer tissue Plasminogen Activator (tPA), the only FDA-approved clot-busting medication for treatment of early ischemic stroke. In contrast, rural residents are often transported to local community hospitals that lack the resources and expertise of PSCs and CSCs. As a result, rural patients often receive less aggressive and effective treatment for their stroke.
Lone Star Stroke (LSS) researchers are working to lessen the disparity in stroke treatment using telemedicine to maximize access to expert stroke treatment for all residents of Texas, regardless of where they live. This endeavor has the potential to save or improve the lives of millions of Texans and serve as a research model for the entire country.
We spoke to LSS researcher Dr. Teddy Wu, assistant professor of neurology at the UT Health Sciences Medical School and director of the Telemedicine Program and Memorial Hermann Mischer Neuroscience Institute, about the benefits of telemedicine. Dr. Wu was part of the UT-Houston research team that was the first in the world to use telemedicine to enroll remote patients in an acute stroke trial.
LSS: The technology of telemedicine (TM) accelerated during the 1990s when you were in medical school. What did TM look like then? Was the technology sensitive enough to conduct a neurological exam?
Dr. Wu: During the late 90’s to early 2000, technology was still not optimal in allowing reliable real-time audio/video conference to allow for safe delivery of medical care. Without inconsistent connectivity, it could not be relied upon for clinical care. With improved broad-band coverage and availability, technology finally was able to sustain the level of reliability for medical care using telemedicine.
LSS: Why did you decide to specialize in neurology?
Dr.Wu: I decided to specialize in stroke neurology during my medical school training at the University of Maryland. I remember shadowing the neurology resident on call and rushing to the emergency room for a stroke code. The patient had complete paralysis of their right side and could not communicate. We gave the patient t-PA and the next day, the patient had regained almost all their strength on the right and speech was dramatically improved. It was at that time that I realized that stroke can be so devastating but with the right treatment, patient outcomes can be improved.
LSS: What is your vision for LSS?
Dr. Wu: My vision for the LSS is to establish a state-wide stroke research network that will increase access to cutting edge clinical trials to all stroke patients across the state of Texas. I feel that TM technology can be used to leverage the resource rich tertiary academic stroke centers to increase the catchment of potential stroke trial participants and also remove the geographic barriers limiting access to advance clinical trials for most patients.
LSS: Strokes mostly occur in middle-aged and older people, in other words, people who did not grow up surrounded by cell phones, video games, and computers. In your experience, how does this patient population respond to the technology of TM?
Dr. Wu: During my career performing neurological consultations using telemedicine, not once did I have a negative reaction from a patient, old or young, or their family members. TM not only allows for the physician to see and hear the patient but the patient also can see and hear the physician. Within seconds of the evaluation, the technology disappears and the patient/family only sees a doctor trying to help them. They are grateful that a stroke specialist can be at their bedside within minutes of arriving to the emergency room, at any time of the day.
LSS: Compared to an in-person exam, how confident are you that TM allows you to conduct a reliable exam? I just realized you probably record these exams, and in doing so other clinicians might have the opportunity to assist with the diagnosis and treatment plan. Does this happen? Do physicians collaborate more using TM?
Dr. Wu: I am the first to say that nothing substitutes a bedside physician that is there physically. However, TM may be the next best thing especially if the bedside physician is not experienced in acute stroke care or not comfortable in performing a neurological exam. There are definite limitations in the TM neurological exam but with assistance from a nurse, the exam is quite reliable for stroke patients which have been demonstrated by many studies. We do not record the interactions with the patients as that would be a breach of HIPAA (federal privacy laws) as we would have to store those files. TM allows physicians that would typically only collaborate by phone to come together, regardless of distance, to work together to deliver the highest quality neurological care.
LSS: One of the reasons TM for stroke care is so important is because the timely administration of tPA is important. What is tPA and can you explain the benefits of tPA?
Dr. Wu: TPA is a stroke clot-busting medication that is used to dissolve blood clots that block blood flow to the patient’s brain tissue in acute ischemic stroke. The medication has been shown to give you a 30 percent improved chance of attaining a better outcome as opposed to not getting the medication. It is effective if given within 3-4.5 hours from symptom onset but does carry a risk of brain bleeding. It is because of the bleeding risk that many clinicians that are not experienced in administering it may be reluctant to give it without the expertise of a stroke neurologist.
LSS: I was surprised to read that tPA utilization remains under 10 percent. Is that for tPA-eligible patients? Compared to the rest of the country, how effectively do ED physicians in Texas utilize tPA?
Dr. Wu: T-PA remains underutilized for many different reasons. Primarily, many patients /family members still lack the awareness of acute stroke symptoms until it is too late, hence they miss the opportunity to get t-PA. Other reasons include the lack of acute neurological expertise in many hospitals across Texas and the rest of the country. As the population in our country ages, more and more strokes are occurring and there is a significant shortage of not only neurologists but stroke neurologists. Most hospitals struggle to attract stroke neurologists to their community for a host of reasons, but with TM, it allows for a single stroke neurologist to cover dozens of hospitals without any geographic barriers.
LSS: How did you become involved with LSS?
Dr. Wu: As the Director of Telemedicine here at UT Health Science Center Houston, we provide acute neurological consultative services to 14 southeast Texas hospitals. UT Houston Stroke Team has been a world leader in acute stroke research and it was always a vision of mine to eventually conduct clinical trials outside of the tertiary academic center using telemedicine. Our team was the first to use telemedicine to help enroll and conduct an acute ischemic stroke trial that is linked with t-PA, investigating the efficacy of transcranial ultrasound to enhance t-PA effectiveness. Partnering with two spoke sites (Baptist Beaumont Hospital and Memorial Hermann-Southwest Hospital) we enrolled 8 patients into the Phase III clinical trial named CLOTBUST-ER study. We did not experience any delays in treatment of significant adverse events.
LSS: Congress, the NIH, the Surgeon General, and the President all advocate for the reduction of racial disparities in healthcare. But despite the awareness campaigns and millions of dollars spent, disparities persist across the board in access and outcomes. However, the study you co-authored with LSS researchers, Dr. Sean Savitz and Dr. James Grotta, about the effects of TM as it relates to stroke care access for racial and ethnic minorities is promising. Can we discuss this study and what it means for TM and under served stroke patients throughout Texas?
Dr. Wu: The state of Texas has one of the largest rural populations in the nation, and only about 50 percent of Texans have access to a Joint Commission primary stroke center within 60 minutes. We found that TM not only increases access to acute stroke expertise in the state of Texas but we found that there were no racial or ethnic disparities in access to stroke expertise provided by TM. TM technology, when properly allocated in areas of needs will improve care to under served stroke patient throughout the state and decrease the morbidity of this burdensome disease.
Author: Jessica Morgan, Research Coordinator and Lone Star Stroke News Editor