key: cord-0960401-4vou2ig2 authors: Vollmuth, Christoph; Miljukov, Olga; Abu‐Mugheisib, Mazen; Angermaier, Anselm; Barlinn, Jessica; Busetto, Loraine; Grau, Armin J.; Guenther, Albrecht; Gumbinger, Christoph; Hubert, Nikolai; Hüttemann, Katrin; Klingner, Carsten; Naumann, Markus; Palm, Frederick; Remi, Jan; Rücker, Viktoria; Schessl, Joachim; Schlachetzki, Felix; Schuppner, Ramona; Schwab, Stefan; Schwartz, Andreas; Trommer, Adrian; Urbanek, Christian; Volbers, Bastian; Weber, Joachim; Wojciechowski, Claudia; Worthmann, Hans; Zickler, Philipp; Heuschmann, Peter U.; Haeusler, Karl Georg; Hubert, Gordian Jan title: Impact of the coronavirus disease 2019 pandemic on stroke teleconsultations in Germany in the first half of 2020 date: 2021-03-22 journal: Eur J Neurol DOI: 10.1111/ene.14787 sha: 31976ad5212a3e9a5025956c2ebe5fc8fcf4eb91 doc_id: 960401 cord_uid: 4vou2ig2 BACKGROUND AND PURPOSE: The effects of the coronavirus disease 2019 (COVID‐19) pandemic on telemedical care have not been described on a national level. Thus, we investigated the medical stroke treatment situation before, during, and after the first lockdown in Germany. METHODS: In this nationwide, multicenter study, data from 14 telemedical networks including 31 network centers and 155 spoke hospitals covering large parts of Germany were analyzed regarding patients' characteristics, stroke type/severity, and acute stroke treatment. A survey focusing on potential shortcomings of in‐hospital and (telemedical) stroke care during the pandemic was conducted. RESULTS: Between January 2018 and June 2020, 67,033 telemedical consultations and 38,895 telemedical stroke consultations were conducted. A significant decline of telemedical (p < 0.001) and telemedical stroke consultations (p < 0.001) during the lockdown in March/April 2020 and a reciprocal increase after relaxation of COVID‐19 measures in May/June 2020 were observed. Compared to 2018–2019, neither stroke patients' age (p = 0.38), gender (p = 0.44), nor severity of ischemic stroke (p = 0.32) differed in March/April 2020. Whereas the proportion of ischemic stroke patients for whom endovascular treatment (14.3% vs. 14.6%; p = 0.85) was recommended remained stable, there was a nonsignificant trend toward a lower proportion of recommendation of intravenous thrombolysis during the lockdown (19.0% vs. 22.1%; p = 0.052). Despite the majority of participating network centers treating patients with COVID‐19, there were no relevant shortcomings reported regarding in‐hospital stroke treatment or telemedical stroke care. CONCLUSIONS: Telemedical stroke care in Germany was able to provide full service despite the COVID‐19 pandemic, but telemedical consultations declined abruptly during the lockdown period and normalized after relaxation of COVID‐19 measures in Germany. The World Health Organization (WHO) declared global pandemic of coronavirus disease 2019 (COVID- 19) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 108 million people worldwide, had caused more than 2.3 million deaths up to 16 February 2020, and is currently undergoing a second wave of infections in various countries [1] . The COVID-19 pandemic has unforeseen implications for all areas of medicine, including the care of patients with cerebrovascular diseases, as neurological departments have redistributed their capacity to ensure the care of patients with COVID-19. Furthermore, a decreased number of hospitalized stroke patients has repeatedly been reported, obviously due to social distancing and isolation or due to concerns regarding an increased in-hospital risk of SARS-CoV-2 infection [2] [3] [4] [5] [6] [7] . On the other hand, there is growing evidence that COVID-19 is linked to acquired hypercoagulability, with an increased risk of venous as well as arterial thrombosis and embolism [8] [9] [10] . In addition, COVID-19-related depletion of angiotensin-converting enzyme 2 and subsequent endothelial dysfunction may also increase the risk of stroke [11] . In hospitalized COVID-19 patients, an ischemic stroke rate up to 3% and a hemorrhagic stroke rate up to 0.5% were reported [12] [13] [14] . Furthermore, COVID-19-associated ischemic strokes are reported to be more severe, with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes [15] . Telemedicine is widely used to facilitate care of stroke patients in regional network hospitals (without a 24/7 presence of a neurologist) by stroke specialists at dedicated network centers. It has been demonstrated that this hub and spoke model improves the quality of stroke care in spoke hospitals, reducing mortality and morbidity of stroke patients [16] . In Germany, 22 telemedical stroke networks provide a substantial part of acute stroke care in rural areas. During the COVID-19 pandemic, it has been recommended to strengthen telemedical stroke networks, because teleneurology can play an important role in protecting patients and physicians from potential exposure to COVID-19 in outpatient and inpatient care (i.e., by optimizing the allocation of treatment resources and minimizing transport of patients between hospitals) [17] . Single-center observations from the United States and Germany report a significant decline in teleconsultations during the peak phase of the COVID-19 pandemic in March and April 2020 [18] [19] [20] [21] . However, the implications of the COVID-19 pandemic for telemedical stroke care have not been analyzed in detail on a national level. On behalf of the German telemedical stroke networks, we analyzed routine data of telemedical consultations in German telemedical networks, hypothesizing a decline of stroke teleconsultations during the COVID-19 pandemic. Furthermore, we compared data of federal states in the southern and nonsouthern part of Germany, as the COVID-19 incidence in southern Germany was higher in the first half of 2020. Using a survey, we assessed potential shortcomings of inhospital and (telemedical) stroke care in Germany in the first half of 2020. [22] , and whether intravenous thrombolysis and/or endovascular treatment was recommended were assessed. Furthermore, the local network coordinators were asked to return a survey focusing on potential shortcomings of in-hospital stroke care as well as telemedical stroke care during the COVID-19 pandemic (Appendix S1), which was cross-referenced with spoke hospitals and network center(s). The incidence of SARS-CoV-2 infections in all federal states of Germany was reported on a weekly basis by the German government's central Public Health Institute (the Robert Koch Institute, Berlin, Germany; https://www.rki.de). As Bavaria and Baden-Württemberg (both in the south of Germany) represented the only two federal states with a mean weekly incidence of more than 40 SARS-CoV-2 infections per 100,000 people, we compared teleconsultations of the participating networks in these two southern federal states of Germany to teleconsultations in the participating networks in other ("nonsouthern") parts of Germany ( Figure 1 , Table S1 ). Two telemedical stroke networks (FAST, Stroke-ARTEV) were allocated according to the localization of spoke hospitals requesting teleconsultations. On 9 January 2020, the WHO declared the first COVID-19-related death worldwide, and on 27 January 2020, the first SARS-CoV-2 infection in Germany was detected. The first death due to COVID-19 in Germany was reported on 9 March 2020. On 16 March 2020, nationwide restriction measures (closing of schools, childcare facilities, and many stores) became effective in Germany. Thus, we defined this date as the start of the COVID-19 pandemicrelated lockdown. In March 2020, we intended to analyze teleconsultations within the period from 1 January 2018 and 30 April 2020. As on 20 April 2020, relaxation of COVID-19 measures was implemented in Germany, we expanded data assessment to 30 June 2020, to be able to assess the impact of relaxation of COVID-19 measures on telemedical care. In March 2020, the following research questions were defined. This study was approved with a waiver of authorization by the data security officer at the University and University Hospital of Würzburg, Germany and was in accordance with the 1964 Declaration of Helsinki and its later amendments. Data of 14 telemedical networks were included in the analysis, including 31 network centers (range = 1-6 centers per network; Figure S1 ) and 155 spoke hospitals (range = 3-24 per telemedical stroke network) in nine federal states of Germany (Table S1 ). Ten of 14 telemedical networks provided additional data on teleconsultations from 1 May 2020 to 30 June 2020. Overall, 67,033 teleconsultations were completed within the observation period in participating networks (Table 1) March 2020 and 19 April 2020 (β 2 = 0.73, p < 0.001; Table 2 , Figure S2A ). The mean daily rate of telemedical consultations in the nonsouthern networks dropped by 21% in the first week of the lockdown (β 4 = 0.79, p = 0.077), and by an additional 15% between 23 March 2020 and 19 April 2020 (β 2 = 0.64, p < 0.001; Table 2, Figure S2B ). After the relaxation of COVID-19 restrictions, the mean daily rate of telemedical consultations increased, but was lower (−6%, p = 0.49) in the two southern federate states and in the nonsouthern federal states (−5%, p = 0.77), if compared to the mean daily rate of telemedical stroke consultations in the time period before the lockdown (between 1 January 2020 and 15 March 2020). Of 55,958 teleconsultations with available diagnosis, 38,895 (69.5%) teleconsultations were stroke related ( Table 2 The survey (Appendix S1) was completed by coordinators of 14 telemedical stroke networks. Telemedical stroke care was limited at one (3%) of 31 network centers, which was reported to be un- In this representative nationwide study, we demonstrate a sig- Figure 1 ). However, the observed fluctuations of (stroke) teleconsultations were similarly observed in federal states with rather high or rather low incidence of SARS-CoV-2 infections (Figure 4 ). During the lockdown period, neither patients' age, gender, nor stroke type and stroke severity showed significant changes. This is not in line with previous publications, indicating a significant decline of the proportion of minor stroke and TIA patients [23] . Published single-center or single-network observations reported increasing or decreasing proportions of patients undergoing recanalization therapy, which was not the case in our analysis [18, 19, 24] . We observed a lower rate of recommendations to perform intravenous thrombolysis during the lockdown, but this was not statistically significant, as similarly reported in the German TEMPiS network (please see Table S1 for details) [20, 21] . This finding may indicate that stroke patients may have arrived at later time points in the spoke hospitals. Our results are also in line with the observed decline of inhospital stroke treatment during March and April 2020 in several health care systems and also in Germany [25] [26] [27] [28] [29] [30] . As a nationwide survey among German neurologists running a certified stroke unit revealed that 93% reported a decrease of hospitalized stroke In-hospital treatment of stroke patients and diagnostic procedures in stroke patients were considered to be normal at the vast majority of stroke centers. This is discrepant from a recent survey including 426 stroke care providers from 55 countries, reporting shortcomings in stroke care in 77% of European respondents [32] . 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Joachim Schessl: data curation (supporting), formal analysis (supporting), investigation (supporting), writing-original draft (supporting). Felix Schlachetzki: data curation (supporting), formal analysis (supporting), investigation (supporting), writing-original draft (supporting). Ramona Schuppner: data curation (supporting), formal analysis (supporting), investigation (supporting), writing-original draft (supporting). Stefan Schwab: data curation We state that the data published are available and anonymized and will be shared on request by email to the corresponding author from any qualified investigator for purposes of replicating procedures and results.