National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic

J Stroke Cerebrovasc Dis. 2021 Oct;30(10):106035. doi: 10.1016/j.jstrokecerebrovasdis.2021.106035. Epub 2021 Aug 7.


Objectives: Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency.

Materials and methods: A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ β nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics.

Results: Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0-6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04).

Conclusions: Among spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.

Keywords: Acute stroke care; Alteplase; Emergency care; Stroke; Telestroke.

MeSH terms

  • Aged
  • Aged, 80 and over
  • COVID-19*
  • Databases, Factual
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Humans
  • Male
  • Middle Aged
  • Practice Patterns, Physicians' / trends*
  • Quality Improvement / trends
  • Quality Indicators, Health Care / trends
  • Remote Consultation / trends*
  • Stroke / diagnosis
  • Stroke / surgery*
  • Thrombolytic Therapy / trends*
  • Time Factors
  • Time-to-Treatment / trends*
  • Tissue Plasminogen Activator / administration & dosage*
  • Treatment Outcome
  • United States


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator