Abstract P178: Rapid Improvement in Timely tPA Administration With Initiation of Telestroke in a Predominantly Rural Catchment Area

Introduction: In acute ischemic stroke (AIS) treatment, reduction in tPA Door-To-Needle time (DTN) by 15 minutes improves functional outcomes. Telestroke has demonstrated timely tPA administration over several years of implementation. However, telestroke care in the rural setting is less well characterized, and many telestroke studies have only shown improvement in DTN over longer periods. We evaluated reduction in DTN over a 6 month period after implementing an internal telestroke process in a rural spoke-hub model in central Texas. Methods: Data was abstracted from local databases from 6 months before and 6 months after initiation of telestroke at each center over years 2017-2019. Patients who presented to the emergency room at 1 of 5 spokes in central Texas with AIS symptoms were included, 393 pre-telestroke and 362 post. Patients who did not receive tPA were excluded. Patients with documented delay such as initial tPA refusal, further imaging or management of acute comorbidities were also excluded, leaving 80 cases, 33 pre-telestroke and 47 post. Chi-square analyses for changes in DTN were used. T-test analysis was used for continuous variables. Primary outcome assessed reduction in DTN with secondary outcome of number of tPA administrations. Results: Total stroke volume did not increase over the study period [average per site pre-telestroke 78.6 (SD 58.1) and post-telestroke 72.4 (SD 45.7)] ( t (4)=0.91, p =0.42). Attainment of <45 minute DTN improved from 18.2% pre- to 48.9% post-telestroke ( p = 0.01), and <60 minute DTN improved from 36.3% to 80.1% ( p <0.0001). Total tPA volume at each site increased over the period, with a moderate effect size though not statistically significant (average per site of 6.6 administrations pre-telestroke to 9.4 post-telestroke, t (4)=-1.72, p =0.16, d=-0 .77) Conclusions: Telestroke within a rural catchment area in central Texas resulted in significant reduction in DTN within 6 months of implementation. This study showed that successful telestroke processes can be implemented in a relatively short time period even in the rural setting. Further investigation of telestroke at rural stroke centers is needed to improve access and quality of care.

Global mapping of urban–rural catchment areas reveals unequal access to services

Using travel time to cities of different sizes, we map populations across an urban–rural continuum to improve on the standard dichotomous representations of urban–rural interactions. We extend existing approaches by 1) building on central place theory to capture the urban hierarchy in access to services and employment opportunities provided by urban centers of different sizes, 2) defining urban–rural catchment areas (URCAs) expressing the interconnection between urban centers and their surrounding rural areas, and 3) adopting a global gridded approach comparable across countries. We find that one-fourth of the global population lives in periurban areas of intermediate and smaller cities and towns, which challenges the centrality of large cities in development. In low-income countries, 64% of the population lives either in small cities and towns or within their catchment areas, which has major implications for access to services and employment opportunities. Intermediate and small cities appear to provide catchment areas for proportionately more people gravitating around them than larger cities. This could indicate that, for countries transitioning to middle income, policies and investments strengthening economic linkages between urban centers and their surrounding rural areas may be as important as investing in urbanization or the rural hinterlands. The dataset provided can support national economic planning and territorial development strategies by enabling policy makers to focus more in depth on urban–rural interactions.

Late diagnosis of HIV: A lookback on cases in North Cumbria

Late diagnosis of HIV remains a threat to personal and public health – both increasing the morbidity and mortality of the person and also increasing the chance of unknowingly transmitting HIV. Many HIV testing initiatives, including those of the British HIV Association (BHIVA), focus on levels of high prevalence (greater than 2:1000). However, late diagnosis can be an issue in areas of low prevalence – areas which can be less densely populated and in some cases classified as rural. In our rural catchment area, late diagnosis is an issue with 67% diagnosed late in 2015 (which is skewed by the single figure diagnoses). This lookback examined the number of missed opportunities for HIV diagnosis over a seven-year period and found that where diagnoses were made late in the context of a person having previously presented for care, unexplained weight loss, blood dyscrasias and lymphadenopathy were the most common presentations that could have triggered a HIV test.