Li Yao, Zhang Mingshan, Ke Weiling, Li Wenwen
Department of Information Systems and Management Engineering, Southern University of Science and Technology, Shenzhen, China.
School of Management, Fudan University, Shanghai, China.
J Med Internet Res. 2025 May 23;27:e72315. doi: 10.2196/72315.
Telemedicine has emerged as a critical tool in the management of acute stroke; yet, its impact on clinical decision-making, particularly in the administration of tissue plasminogen activator (tPA), remains underexplored. Understanding how telemedicine influences tPA use and subsequent patient outcomes, such as hemiplegia, is critical for optimizing stroke care protocols.
This study aims to assess whether the adoption of telemedicine influences treatment decisions regarding tPA administration in patients with stroke. In addition, we used a causal mediation framework to examine the causal path between telemedicine adoption and the occurrence of hemiplegia via tPA use. Furthermore, we conducted a moderated mediation analysis to investigate the extent to which regional differences (metropolitan vs nonmetropolitan locations) impact this mediated relationship.
We analyzed data of patients with stroke from Florida's State Emergency Department Database (SEDD), State Inpatient Database (SID), and the Healthcare Information and Management Systems Society (HIMSS) database, covering the years 2010 to 2017, with a focus on telemedicine adoption. The final sample includes 314,665 visits from patients with stroke. A fixed-effects model was used to examine the relationship between telemedicine adoption and tPA use and between tPA use and hemiplegia occurrence. A causal mediation framework was then applied to estimate the average direct effect and the average causal mediation effect of telemedicine on hemiplegia through tPA use. In addition, a moderated mediation analysis was performed to explore how metropolitan status influences the mediation process.
We found that telemedicine adoption is associated with a 1% decrease in tPA use (coefficient=-0.010; 95% CI -0.013 to -0.007; P<.001), and that the use of tPA is associated with a 23.7% increased probability of hemiplegia (coefficient=0.237, 95% CI 0.231-0.243; P<.001). Consequently, telemedicine adoption was found to reduce the likelihood of hemiplegia by decreasing tPA usage. The causal mediation analysis shows a negative average causal mediation effect (average causal mediation effect=-0.002, 95% CI -0.003 to -0.002; P<.001), suggesting that telemedicine adoption reduces hemiplegia occurrence, while the average direct effect is not statistically significant (average direct effect=-0.002, 95% CI -0.007 to 0.004; P>.10). Importantly, the positive effect of telemedicine on reducing hemiplegia is observed only among metropolitan patients.
This study provides evidence that telemedicine adoption can improve stroke care by reducing tPA administration, thereby lowering the risk of hemiplegia. However, the benefits appear more pronounced in metropolitan areas, highlighting potential regional disparities in stroke care. These findings underscore the importance of targeted interventions to ensure equitable access to telemedicine, especially in rural and underserved areas. Policy makers should focus on enhancing telemedicine infrastructure and training in these regions to optimize stroke care and reduce health inequities.
远程医疗已成为急性中风管理中的一项关键工具；然而，其对临床决策的影响，尤其是在组织型纤溶酶原激活剂（tPA）给药方面，仍未得到充分探索。了解远程医疗如何影响tPA的使用以及随后的患者预后，如偏瘫，对于优化中风护理方案至关重要。
本研究旨在评估采用远程医疗是否会影响中风患者tPA给药的治疗决策。此外，我们使用因果中介框架来研究通过使用tPA，远程医疗的采用与偏瘫发生之间的因果路径。此外，我们进行了调节中介分析，以调查区域差异（大都市与非大都市地区）在多大程度上影响这种中介关系。
我们分析了来自佛罗里达州州立急诊科数据库（SEDD）、州住院数据库（SID）和医疗保健信息与管理系统协会（HIMSS）数据库中2010年至2017年中风患者的数据，重点关注远程医疗的采用情况。最终样本包括314665例中风患者的就诊记录。使用固定效应模型来研究远程医疗的采用与tPA使用之间以及tPA使用与偏瘫发生之间的关系。然后应用因果中介框架来估计远程医疗通过使用tPA对偏瘫的平均直接效应和平均因果中介效应。此外，进行了调节中介分析，以探讨大都市地位如何影响中介过程。
我们发现采用远程医疗与tPA使用减少1%相关（系数=-0.010；95%置信区间-0.013至-0.007；P<.001），并且使用tPA与偏瘫发生概率增加23.7%相关（系数=0.237，95%置信区间0.231-0.243；P<.001）。因此，发现采用远程医疗通过减少tPA使用降低了偏瘫的可能性。因果中介分析显示平均因果中介效应为负（平均因果中介效应=-0.002，95%置信区间-0.003至-0.002；P<.001），表明采用远程医疗可减少偏瘫的发生，而平均直接效应无统计学意义（平均直接效应=-0.002，95%置信区间-0.007至0.004；P>.10）。重要的是，仅在大都市患者中观察到远程医疗对减少偏瘫的积极作用。
本研究提供的证据表明，采用远程医疗可通过减少tPA给药来改善中风护理，从而降低偏瘫风险。然而，这种益处在大都市地区似乎更为明显，凸显了中风护理中潜在的区域差异。这些发现强调了有针对性干预措施的重要性，以确保公平获得远程医疗服务，特别是在农村和服务不足地区。政策制定者应专注于加强这些地区的远程医疗基础设施和培训，以优化中风护理并减少健康不平等。
