集中式与分散式系统中的卒中溶栓治疗（赫尔辛基和远程医疗综合卒中护理网络项目）
Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network).
作者信息
Hubert Gordian J, Meretoja Atte, Audebert Heinrich J, Tatlisumak Turgut, Zeman Florian, Boy Sandra, Haberl Roman L, Kaste Markku, Müller-Barna Peter
机构信息
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
出版信息
Stroke. 2016 Dec;47(12):2999-3004. doi: 10.1161/STROKEAHA.116.014258. Epub 2016 Nov 10.
BACKGROUND AND PURPOSE
Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system.
METHODS
We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki and Province of Uusimaa, Finland, 1.56 million inhabitants, 9096 km) and the decentralized TeleStroke Unit network in a predominantly rural area (Telemedical Project for Integrative Stroke Care [TEMPiS], South-East Bavaria, Germany, 1.94 million inhabitants, 14 992 km). All consecutive tPA treatments were prospectively registered. We compared tPA rates per total ischemic stroke admissions in the Helsinki and TEMPiS catchment areas. For delay comparisons, we excluded patients with basilar artery occlusions, in-hospital strokes, and those being treated after 270 minutes.
RESULTS
From January 1, 2011, to December 31, 2013, 912 patients received tPA in Helsinki University Central Hospital and 1779 in TEMPiS hospitals. Area-based tPA rates were equal (13.0% of 7017 ischemic strokes in the Helsinki University Central Hospital area versus 13.3% of 14 637 ischemic strokes in the TEMPiS area; P=0.078). Median prehospital delays were longer (88; interquartile range, 60-135 versus 65; 48-101 minutes; P<0.001) but in-hospital delays were shorter (18; interquartile range, 13-30 versus 39; 26-56 minutes; P<0.001) in Helsinki University Central Hospital compared with TEMPiS with no difference in overall delays (117; interquartile range, 81-168 versus 115; 87-155 minutes; P=0.45).
CONCLUSIONS
A decentralized telestroke thrombolysis service can achieve similar treatment rates and time delays for a rural population as a centralized system can achieve for an urban population.
背景与目的
急性缺血性卒中患者早期接受组织型纤溶酶原激活剂（tPA）静脉溶栓治疗效果更佳。及时送达治疗颇具挑战，尤其是在距离较远的农村地区。我们比较了一个大型、分散式远程医疗系统和一个组织完善、大型、集中式单医院系统的延误情况及治疗率。
方法
我们分析了赫尔辛基大学中心医院的集中式系统（芬兰赫尔辛基和新地区，156万居民，9096千米）以及一个主要为农村地区的分散式远程卒中单元网络（德国巴伐利亚东南部的综合卒中护理远程医疗项目[TEMPiS]，194万居民，14992千米）。所有连续接受tPA治疗的患者均进行前瞻性登记。我们比较了赫尔辛基和TEMPiS服务区域内每例缺血性卒中入院患者的tPA治疗率。为比较延误情况，我们排除了基底动脉闭塞患者、院内卒中患者以及270分钟后接受治疗的患者。
结果
2011年1月1日至2013年12月31日，912例患者在赫尔辛基大学中心医院接受tPA治疗，1779例在TEMPiS医院接受治疗。基于区域的tPA治疗率相当（赫尔辛基大学中心医院服务区域内7017例缺血性卒中患者中有13.0%接受治疗，TEMPiS服务区域内14637例缺血性卒中患者中有13.3%接受治疗；P = 0.078）。与TEMPiS相比，赫尔辛基大学中心医院的院前中位延误时间更长（88分钟；四分位间距为60 - 135分钟，而TEMPiS为65分钟；48 - 101分钟；P < 0.001），但院内延误时间更短（18分钟；四分位间距为13 - 30分钟，而TEMPiS为39分钟；26 - 56分钟；P < 0.001），总体延误无差异（117分钟；四分位间距为81 - 168分钟，而TEMPiS为115分钟；87 - 155分钟；P = 0.45）。
结论
对于农村人口，分散式远程卒中溶栓服务可实现与集中式系统对城市人口所实现的相似治疗率和时间延误。
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