We appreciate the interest that Vatankhah and Audebert have in our recent article and accompanying editorial. We thank them for providing information on their numerous publications generated from the TEMPiS study.1 The network of hospitals in Bavaria that make up TEMPiS has demonstrated that telemedicine can be an effective way of delivering stroke expertise to hospitals that had previously lacked extensive experience with thrombolytic therapy. It is true that the nonrandomized, unblinded, open-intervention TEMPiS study showed that specialized stroke treatment in TEMPiS telemedicine network hospitals independently reduced the probability of a poor outcome. However, it is worth noting that the positive effects of being in-network were likely not simply the result of telemedicine. The intervention, and thus the systematic difference between in-network and out-of-network hospitals, included implementation of stroke wards, stroke teams, continuous medical education for the personnel of the participating network hospitals, collaboration with stroke neurologists, and the telemedical support. Interestingly, the overall rate of teleconsultation among the in-network hospitals was only 36%.
For large geographic regions, telemedicine provides an impetus for better organization and standardization of care for stroke. Recruitment rates for acute stroke trials are influenced by the organizational structure of the research team.2 Advantages of TEMPiS and similarly structured regional telestroke networks could make phase 3 clinical stroke trials more cost- and time-efficient. For instance, hub hospitals engaged in acute stroke trials could use telemedicine to screen patients and obtain consent as well as to enroll, randomize, treat, and even follow up patients at remote spoke hospitals.
We agree that long-term stroke telemedicine patient outcome and safety data, beyond thrombolysis decision making, are needed from an increased number of international networks. Additional questions that require an answer are as follows: (1) Is stroke telemedicine cost-effective? (2) What is the most favorable stroke telemedicine network model: hub-and-spoke or third-party consult? (3) Must telemedicine-treated acute stroke patients be transferred from a rural spoke hospital to a primary stroke center to derive long-term benefit? (4) How can telestroke practitioners best overcome intrastate, interstate, and even international licensing, credentialing, privilege, marketplace, business, and malpractice insurance issues for a consultative modality that knows no geographic limits?3
The stroke telemedicine review by Demaerschalk et al4 also highlighted that, despite the fact that many international centers are engaged in telestroke practice and research, the field is still missing common, standardized, and uniformly applied measures of telestroke quality of care and acceptable guidelines for telestroke practice.
References
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