Abstract TMP63: Region-wide, Prehospital Mobile Tele-Evaluation by a Central Neurologist Reduces Disparities in Lytic Therapy for Acute Stroke

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Background: Disparities in the delivery of acute stroke care among diverse race-ethnic populations have been well documented, including lower rates of use of intravenous thrombolytic therapy and longer door to needle times. We sought to determine if prehospital mobile telemedical patient evaluation by a neurologist responding to all stroke ambulance transports in a region would reduce these disparities.

Methods: Subjects were participants in the Phase 3 NIH Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial of prehospital magnesium vs. placebo within 2 hours from symptom onset. A central neurologist performed mobile prehospital tele-evaluation, using audio or video smartphones, of all study candidate patients being transported by 315 ambulances to 60 hospitals throughout Los Angeles and Orange County. After confirming likely stroke and eliciting informed consent, the neurologist spoke to the attending ED physician in the destination hospital and gave pre-arrival report.

Results: Of 1700 subjects, race-ethnic distribution included: white, non-Hispanic - 929 (55%): white, Hispanic - 402 (24%); black - 219 (13%); and Asian - 139 (8%).. Among the 1245 (73%) patients with a final diagnosis of acute cerebral ischemia (ACI), 444 (36%) were treated with IV tPA. In all ACI patients, the median time from door to imaging was 28 minutes (IQR 19-42). In the tPA-treated patients, median door to imaging time was 25 mins (18-35) and door to needle time 79 mins (62-104);. There were no differences in rates of tPA utilization among non-Hispanic Whites (35%), Blacks (35%) and Latinos (35%) with cerebral ischemia. There were also no significant differences in door to imaging (24 vs. 28 vs. 25 minutes, p=0.39 or door to needle (83 vs. 77 vs. 78 minutes, p=0.57)

Conclusions: Central neurologist mobile tele-evaluation of potential stroke patients transported by all ambulances throughout a region with 13.1 million persons is feasible, and is associated with resolution of disparities in use and speed of thrombolytic therapy for acute ischemic stroke.

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