Impact of telemedicine implementation in thrombolytic use for acute ischemic stroke: the University of Pittsburgh Medical Center telestroke network experience.

BACKGROUND: Intravenous thrombolysis is the only therapy for acute ischemic stroke that is approved by the US Food and Drug Association. The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care. METHODS: All consecutive admissions for stroke were reviewed for 1 year before telemedicine implementation and for variable periods thereafter. A retrospective review identified 2588 admissions for acute stroke between March 2005 and December 2008 at 12 hospitals participating in a telestroke network, including 919 patients before telemedicine was available and 1669 patients after telemedicine was available. The primary outcome measure was the rate of intravenous tissue plasminogen activator (IV tPA) use before and after telemedicine implementation. RESULTS: One hundred thirty-nine patients received IV tPA in both study phases, with 26 (2.8%) patients treated before starting telemedicine and 113 (6.8%) after starting telemedicine (P < .001). Incorrect treatment decisions occurred 7 times (0.39%), with 2 (0.2%) pretelemedicine and 5 (0.3%) posttelemedicine (P = .70). Arrivals within 3 hours from symptom onset were more frequent in the posttelemedicine compared to the pretelemedicine phases (55 [6%] vs 159 [9.5%]; P = .002). Among the patients treated with IV tPA, symptomatic intracranial hemorrhage occurred in 2 patients (1 [10.7%] pretelemedicine vs 1 [1.8%] posttelemedicine; P = .34). CONCLUSIONS: Telestroke implementation was associated with an increased rate of thrombolytic use in remote hospitals within the telemedicine network.

Disability in late-life major depression: patterns of self-reported task abilities, task habits, and observed task performance.

This article describes patterns of concordance/discordance between self-reported abilities ("can do") and habits ("does do") and observed task performance of daily living tasks in three groups of older adults: late life depression with mild cognitive impairment (n=53), late life depression without mild cognitive impairment (n=64), and non-depressed, cognitively normal controls (n=31). Self-reported data were gathered by interview in participants' homes, followed by observation of task performance. Significant differences in the patterns of response were found between controls and respondents with both late life depression and mild cognitive impairment for the cognitive instrumental activities, and between the two depressed groups and controls for the physical instrumental activities. For both sets of activities, controls exhibited the greatest overestimation of task performance. No differences were found among the groups for the less complex functional mobility and personal care tasks. However, for the more complex instrumental activities, concordance was close to, or less than, chance. The findings led us to conclude that when performance testing is not feasible, self-reports of functional status that focus on habits may be more accurate than those that focus on abilities.

Measuring stroke survivors' functional status independence: five perspectives.

An understandable measure to describe disabilities after stroke is important for clinical practice; practitioners often use multiple measures that contain different scoring systems and scales to rate activities of daily living (ADL) independence. We compared the construct of independence in five measures used with stroke survivors. The measures evaluated independence of the stroke survivors somewhat differently. The Rasch analysis Partial Credit Model converted items from these measures to a single metric, yielding an item difficulty hierarchy of all items from the measures. Data from the measures should be interpreted carefully because other concepts or constructs in addition to ADL independence are included in some of the measures. Rasch diagnostics regarding construct validity and reliability of the combined measures also indicated that these measures are not interchangeable. Although the items of the combined ADL measures were unidimensional, they measured independence from multiple perspectives, and the scale of the combined measures was not linear.