Tenecteplase real-world data: A three phase sequential comparison.

INTRODUCTION: The New Zealand (NZ) Central Region Stroke Network, serving 1.17 million catchment population, changed to tenecteplase for stroke thrombolysis in 2020 but was forced to revert to Alteplase in 2021 due to a sudden cessation of drug supply. We used this unique opportunity to assess for potential before and after temporal trend confounding. PATIENTS AND METHODS: In NZ all reperfused patients are entered prospectively into a national database for safety monitoring. We assessed Central Region patient outcomes and treatment metrics over three time periods: alteplase use (January 2018-January 2020); during switch to tenecteplase (February 2020-February 2021) and after reverting to alteplase (February 2021-December 2022) adjusting regression analyses for hospital, age, onset-to-needle, NIHSS, pre-morbid mRS and thrombectomy. RESULTS: Between January 2018 and December 2022, we treated 1121 patients with Alteplase and 286 with tenecteplase. Overall, patients treated with tenecteplase had greater odds of favorable outcome ordinal mRS [aOR = 1.43 (95% CI = 1.11-1.85)]; shorter door-to-needle (DTN) time [median 52 (IQR 47-83) vs 61 (45-84) minutes, p < 0.0001] and needle to groin (NTG) times [118 (74.5-218.5) vs 185 (118-255); p = 0.02)]. Symptomatic intracerebral hemorrhage (sICH) rate was lower in tenecteplase group [aOR 0.29 (0.09-0.95)]. Findings similarly favored tenecteplase when comparing tenecteplase to only the second alteplase phase. There was no inter-group difference when comparing the two alteplase phases. CONCLUSIONS: Our results suggest that previously reported benefits from tenecteplase in a real-world setting were not likely attributable to a temporal confounding.

Impact of discontinuation of telestroke: the Nelson experience.

AIM: In 2016, five Central New Zealand hospitals piloted a successful telestroke service that has since transitioned to 'business as usual'. Nelson Hospital elected to opt out of the service after completion of the pilot. This paper reports the impact of telestroke service discontinuation on service provision within a regional and national context. METHODS: This is a sequential comparison of three time periods: six months pre-telestroke, six months during telestroke and six months post-telestroke pilot. Main outcomes were thrombolysis rate and door-to-needle time comparing the period with telestroke to the periods without. RESULTS: Over the 18-month period the thromboloysis rate was 8.5% (6/71) over the six months pre, 23.0% (14/61) over the six months during and 7.9% (5/63) over the six months post the use of telestroke support. The odds ratio (95% CI) of being thrombolysed with versus without telestroke support was 3.33 (1.41-7.86); p=0.006). Patients receiving thrombolysis within 60 minutes of arrival were 50% before, 64% during and 20% after telestroke (OR (95%CI) 3.15 (0.61-16.3); p=0.16). Other hospitals that continued with telestroke maintained their rates and door-to-needle times between pilot and post-pilot periods. CONCLUSION: These findings indicate that the transient implementation of telestroke was insufficient to upskill provincial hospital generalist clinicians to sustain high thrombolysis rates.

Impact and implementation of a sustainable regional telestroke network.

BACKGROUND: Telestroke uses videoconferencing technology to allow off-site experts to provide stroke thrombolysis decision support to less experienced front line clinicians. AIM: To assess the impact of a new telestroke service on thrombolysis rates and door-to-needle times in participating provincial hospitals and service resources to aid transition to a sustainable telestroke service. METHODS: This is a sequential comparison of 'pre' (December 2015 to May 2016) and 'post' (June 2016 to December 2016) implementation outcomes. The main outcomes were thrombolysis rate and door-to-needle time. All patient data were captured prospectively in a central database. Data captured and analysed also included technical problems, consumer and clinician feedback, and additional service resources required. RESULTS: Over the study period, 164 telestroke assessments were completed, including the 'hub' hospital. Among the participating provincial hospitals, 21 of 343 patients (6.1%) were thrombolysed in the 6-months prior to June 2016 and 50 of 318 patients (15.7%) during the 6-month following implementation of telestroke; odds ratio 2.86 (95% confidence interval 1.68-4.89); P = 0.0001. Overall, mean (standard deviation) regional hospital door-to-needle time reduced from 79.6 (31.4) to 62.7 (23.3) min (P = 0.015). Videoconferencing failure occurred in 4.8% of cases. Consumer and clinician feedback was positive. The main resource challenge was doubling of out-of-hours neurologist workload. CONCLUSION: Telestroke was associated with a significant increase in thrombolysis rate and reduction in door-to-needle time in provincial hospitals indicating improved patient care. Quantification of the extra neurologist workload allowed for a seamless transition to 'business as usual' using a novel annual subscription funding and service model.