The clinical care and short-term outcomes after a minor ischemic stroke or transient ischemic attack (TIA) remained stable in Ontario, Canada, following the widespread implementation of telemedicine in 2020, according to a new report.
Clinical outcomes, access to outpatient visits, and medication renewals were comparable to those seen before the COVID-19 pandemic prompted virtual visits.
“TIAs often precede major disabling strokes and require urgent follow-up in stroke prevention clinics after an initial emergency department assessment,” study author Amy Yu, MD, a stroke neurologist at Sunnybrook Health Sciences Centre in Toronto, told Medscape Medical News.
“Many clinics made an abrupt switch to telemedicine at the beginning of the COVID-19 pandemic,” she said. “We wanted to evaluate whether care and outcomes for patients with TIA or minor stroke remained stable with the increasing use of telemedicine.”
The study was published on October 4 in CMAJ Open.
Rapid-access outpatient clinics serve as the backbone of strategies for secondary stroke prevention, the study authors write. Before the pandemic, the use of telemedicine in Ontario for patients with stroke was mostly limited to the Ontario Telestroke Program, which provides support for stroke management in emergency departments of primary stroke centers. Some outpatient telemedicine care was also provided to patients in remote regions.
At the beginning of the pandemic, however, telemedicine was more broadly adopted, and new physician fee codes for outpatient telemedicine care were introduced in Ontario. This allowed widespread use of direct-to-patient telemedicine care without the need for additional approval. Physician reimbursement was unchanged for services provided in person or via telemedicine.
The investigators conducted a population-based cohort study to analyze administrative data for patients with a minor ischemic stroke or TIA who were discharged from an emergency department in Ontario before the pandemic (April 2015 to March 2020) and after the widespread use of telemedicine during the pandemic (April 2020 to March 2021). They evaluated care outcomes, including physician visits and medication renewals, and clinical outcomes, such as hospital admissions and deaths within 90 days of the emergency department discharge date.
The research team identified 47,601 patients discharged from an emergency department. There were 35,695 cases of TIA and 11,906 cases of minor ischemic stroke. Patient characteristics in the pretelemedicine and telemedicine periods were balanced.
Telemedicine visits increased after April 2020; 83% of patients had at least one telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before the pandemic.
Overall, outpatient physician visits within 90 days remained unchanged, at 92.9% before the pandemic and 94% after widespread telemedicine was implemented. Clinical investigations — such as neuroimaging, vascular imaging, and echocardiogram studies — didn’t change. For patients older than 65 years, renewals for antihypertensive, antihyperlipidemia, and antihyperglycemia medications were also unchanged.
Moreover, clinical outcomes were similar before and after 2020. The adjusted hazard ratios were 0.97 for 90-day all-cause admission, 1.06 for stroke admission, and 1.07 for death.
“The rapid increase in the use of telemedicine was consistent with the practice shift during the pandemic that was known,” said Yu. “We were very reassured that the care patients received and their health outcomes were stable, despite interruptions in in-person clinics, with the use of telemedicine.”
Potentially Improved Access
Telemedicine appears to be an effective healthcare delivery method that can complement in-person care, the study authors write. Policies that continue physician reimbursement for telemedicine services could help.
“The coexistence of in-person and telemedicine care may have benefits beyond protection against infectious disease exposure,” said Yu. “Telemedicine can potentially improve access to stroke experts for patients living in remote regions, reduce time and costs related to travel for the patient, have environmental benefits, and facilitate caregiver engagement.”
For instance, Yu and colleagues found that certain patient groups were more apt to miss follow-up visits. About 15% of patients didn’t have any physician follow-up within 28 days of discharge, and they were more likely to live in neighborhoods in the lowest quintile of income and in rural regions.
The research team also found differences in the pattern of visits with family physicians in comparison with stroke specialists. During the telemedicine period, a higher proportion of patients had a follow-up with a specialist, yet a lower proportion had a follow-up with a family physician. At the same time, among patients who were seen by a physician, a higher proportion of patients had three or more visits with a family physician or specialist after telemedicine was widely adopted.
Commenting on the findings for Medscape, Ruth Hall, PhD, an adjunct scientist for the cardiovascular research program at ICES Central in Toronto, said, “It is reassuring that this study shows phone or video physician follow-up visits are not associated with an increase in hospitalizations or death, nor a decrease in secondary stroke prevention best practice care processes.”
Hall, who wasn’t involved with this study, has researched stroke care and outcomes across Ontario, including in rural areas.
“Follow-up after a TIA- or minor-stroke-related emergency department visit requires time and expense for the patient and caregiver, and it will be important to ensure their experiences and preferences of follow-up care are considered at the time of discharge,” she said. “For those residing in rural or low-income areas, other approaches may be necessary, and engagement with individuals in these communities can help inform approaches.”
The study was supported by the Heart and Stroke Foundation of Canada. Yu contributed to the funding acquisition and reported receiving a grant and National New Investigator Award from the foundation, as well as funding from the Ontario Health Data Platform. Hall has disclosed no relevant financial relationships.
CMAJ Open. Published October 4, 2022. Full text
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.