Efficacy and Safety of the Telestroke Drip-And-Stay Model: A Systematic Review and Meta-Analysis

J Stroke Cerebrovasc Dis. 2021 Apr;30(4):105638. doi: 10.1016/j.jstrokecerebrovasdis.2021.105638. Epub 2021 Feb 2.

Abstract

Objectives: To compare outcomes between two models of acute ischemic stroke care. Namely 1) "drip-and-stay", i.e. IV tissue plasminogen activator (tPA) administered at a spoke hospital in a telestroke network, with the patient remaining at the spoke, versus 2) "drip-and-ship", i.e. tPA administered at a spoke hospital with subsequent patient transfer to a hub hospital, and 3) "hub", i.e. tPA and subsequent treatment at a hub hospital.

Materials and methods: We performed a systematic review and meta-analysis according to PRISMA guidelines. Literature searches of MEDLINE, Embase, and Cochrane from inception-October 2019 included randomized control trials and observational cohort studies comparing the drip-and-stay model to hub and drip-and-ship models. Outcomes of interest were functional independence (modified Rankin Scale ≤ 1), symptomatic intracranial hemorrhage (sICH), mortality, and length of stay. Pooled effect estimates were calculated using a fixed-effects meta-analysis and random-effects Bayesian meta-analysis. Non-inferiority was calculated using a fixed-margin method.

Results: Of 2806 unique records identified, 10 studies, totaling 4,164 patients, fulfilled the eligibility criteria. Meta-analysis found no significant difference in functional outcomes (mRS0-1) (6 studies, RR=1.09, 95%CI 0.98-1.22, p=0.123), sICH (8 studies, RR=0.98, 95%CI 0.64-1.51, p=0.942), or 90-day mortality (5 studies, RR=0.98, 95%CI 0.73-1.32, p=0.911, respectively) between patients treated in a drip-and-stay model compared to patients treated in drip-and-ship or hub models. There was no significant heterogeneity in these outcomes. Drip-and-stay outcomes (mRS 0-1, sICH) were non-inferior when compared to the combined group.

Conclusions: Our findings indicate that drip-and-stay is non-inferior to current models of drip-and-ship or hub stroke care, and may be as safe and as effective as either.

Keywords: Cerebrovascular disease/stroke; Infarction; Models of care; Outcomes research; Patient safety; Safety; Telemedicine.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Infusions, Intravenous
  • Intracranial Hemorrhages / etiology
  • Ischemic Stroke / diagnosis
  • Ischemic Stroke / mortality
  • Ischemic Stroke / therapy*
  • Length of Stay
  • Male
  • Middle Aged
  • Observational Studies as Topic
  • Patient Transfer*
  • Randomized Controlled Trials as Topic
  • Recovery of Function
  • Risk Assessment
  • Risk Factors
  • Telemedicine*
  • Thrombolytic Therapy* / adverse effects
  • Thrombolytic Therapy* / mortality
  • Time Factors
  • Time-to-Treatment
  • Tissue Plasminogen Activator / administration & dosage*
  • Tissue Plasminogen Activator / adverse effects
  • Treatment Outcome

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator