Telestroke: Barriers to the Transition.

Only few patients affected by acute stroke are treated with thrombolytic therapy or endovascular treatment, especially in rural or underserved areas/hospitals. A survey of national scientific societies and stroke experts in 44 European countries conducted in 2019 showed that 7.3% of all patients with an ischemic stroke in Europe received intravenous thrombolysis (IVT), whereas 13 countries reported IVT rates of 10% or more (1). In rural areas, the problem is compounded by a general lack of stroke specialists with experience using tissue plasminogen activator on site. Telemedicine in stroke, or telestroke, has emerged as one of the most successful strategies to effectively treat acute ischemic stroke with IVT also in remote hospitals, providing the experience and competence of stroke teams to as many patients as possible (2–4). Remote evaluation via videoconference of the National Institute of Health Stroke Scale (NIHSS) has shown similar interrater reliability to on-site examination (5) and encouraging data reported the potential benefit of telestroke in identifying patients potentially eligible for endovascular treatment (6–8). At least home-based tele rehabilitation—defined as the use of telecommunication devices (telephone, videophone) by a clinician to offer evaluation and distance support for disabled persons living at home—is an excellent model to meet the rehabilitation needs of stroke survivors in resource-limited settings (9). There are many upfront costs involved with the initial installation of telestroke; training practitioners in its usage and reimbursement ambiguity creates limits, but despite this, telestroke appears cost-effective compared to usual care, as costs are upfront but benefits of improved stroke care are lifelong (10). Switzer et al. estimated that compared with no network, a telestroke system may result in more IVT, more endovascular stroke therapies, and more stroke patients discharged independently, and despite upfront and maintenance expenses, it results in greater cost savings for the entire network (11). An Acute Telestroke Programme commenced incrementally across Western Australia during 2016–2017. An economic evaluation study on effectiveness and cost-effectiveness of this program is, to date, ongoing (12). The latest American Stroke Association guidelines for the early management of adults with ischemic stroke recommend the implementation of telemedicine in order to increase access to acute stroke care (13). Despite the potential improvement of healthcare quality, also supported by guideline recommendations (14), the transition to larger telemedicine-based stroke networks remains marginal in Europe and Italy (15). The 2020 COVID-19 pandemic boosted the implementation of Information and Communication Technology (ICT) resources in healthcare systems and in the setting of stroke. The approach of the healthcare authorities to the topic is general without any specific referral to telestroke, which lies inside the digital health issues. Some authors analyzed structural and nonstructural modifications of acute stroke care pathways undertaken at regional healthcare institutions in Italy after the COVID-19 pandemic, concluding that telemedicine is one of the best answers to approach stroke care in pandemic times (16). The implementation of the existing telestroke networks may minimize futile transfers; telestroke pathways starting at the patient's home could reduce unnecessary contact and reduce the risk of contagion; telemedicine at hospital level is crucial to evaluate patients suspected of having an acute neurological pathology in the COVID units or even in emergency departments. International medical authorities in late December 2020 and at the beginning of 2021 released various statements and recommendations to normalize the framework of digital medicine for both device selection and regulatory measures. If barriers such as low reimbursement rates and high equipment costs will be reduced, telestroke has the potential to diminish the striking geographical disparities of acute stroke care. Here we analyze the Food and Drug Administration (FDA), European Medicines Agency, and other national statements on this topic to address the best strategies and tactics to face this transition.