title: TeleStroke units serving as a model of care in rural areas: 10-year experience of the TeleMedical project for integrative stroke care.
abstract: OBJECTIVE
  Stroke Unit care improves stroke prognosis and is recommended for all patients with stroke. In rural areas, population-wide implementation of Stroke Units is challenging. Therefore, the TeleMedical Project for integrative Stroke Care (TEMPiS) was established in 2003 as a TeleStroke Unit network to overcome this barrier in Southeast Bavaria/Germany. Evaluation of its implementation between 2003 and 2005 had revealed improved process quality and clinical outcomes compared with matched hospitals without TeleStroke Units. Data on sustainability of these effects are lacking.
  
  
  METHODS
  Effects on the stroke care of the local population were analyzed by using data from official hospital reports. Prospective registries from 2003 to 2012 describe processes and outcomes of consecutive patients with stroke and transient ischemic attack treated in TEMPiS hospitals. Quality indicators assess diagnostics, treatment, and outcome. Rates and timeliness of intravenous thrombolysis as well as data on teleconsultations and secondary interhospital transfers were reported over time.
  
  
  RESULTS
  Within the covered area, network implementation increased the number of patients with stroke and transient ischemic attack treated in hospitals with (Tele-)Stroke Units substantially from 19% to 78%. Between February 2003 and December 2012, 54 804 strokes and transient ischemic attacks were treated in 15 regional hospitals, and 31 864 teleconsultations were performed. Intravenous thrombolysis was applied 3331 stroke cases with proportions increasing from 2.6% to 15.5% of all patients with ischemic stroke. Median onset-to-treatment times decreased from 150 (interquartile range, 127-163) to 120 minutes (interquartile range, 90-160) and door-to-needle times from 80 (interquartile range, 68-101) to 40 minutes (interquartile range, 29-59).
  
  
  CONCLUSIONS
  TeleStroke Units can provide sustained high-quality stroke care in rural areas.
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany. peter.mueller-barna@khagatharied.de.
authors.forename: Peter
authors.initials: P
authors.lastname: Müller-Barna
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Gordian J
authors.initials: GJ
authors.lastname: Hubert
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Sandra
authors.initials: S
authors.lastname: Boy
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Bogdahn
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Silke
authors.initials: S
authors.lastname: Wiedmann
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Peter U
authors.initials: PU
authors.lastname: Heuschmann
authors.affiliation: From the Department of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Germany (P.M.-B., G.J.H.); Department of Neurology, Krankenhaus Agatharied, Hausham, Germany (P.M.-B.); Department of Neurology, University Hospital Regensburg, Regensburg, Germany (S.B., U.B.); Institute of Clinical Epidemiology and Biometry (S.W., P.U.H.) and Comprehensive Heart Failure Center (S.W., P.U.H.), University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany (S.W., P.U.H.); and Klinik und Hochschulambulanz für Neurologie (H.J.A.) and Center for Stroke Research (H.J.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Heinrich J
authors.initials: HJ
authors.lastname: Audebert
mesh_terms: D002309:Cardiology / Q000458:organization & administration*; D005843:Geography; D005858:Germany; D006764:Hospitals, Community; D006801:Humans; D016730:Program Development; D019984:Quality Indicators, Health Care; D012042:Registries; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D020521:Stroke / Q000628:therapy*; D017216:Telemedicine / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D016896:Treatment Outcome
keywords: quality indicators, health care; stroke; telemedicine; thrombolytic therapy