Comparative performance of spoke centers versus telemedicine service in the emergency activation of ST elevation myocardial infarction network: Insights from the “detective” registry

Abstract

Introduction

Telemedicine has implemented the regional networks between 24/7 catheterization laboratories of “Hub” hospitals and the Territorial Emergency Medical Service (TEMS) to reduce time to diagnosis and treatment of ST segment elevation myocardial infarction (STEMI). Telemedicine has been conversely hypothesized to carry an excess of false-positive diagnoses; however, comparisons with a traditional diagnostic process at non-percutaneous coronary intervention capable (“Spoke”) hospitals are lacking.

Methods

This multicenter case–control study retrospectively included 1001 consecutive patients with an initial diagnosis of STEMI or very high risk (VHR) non-ST elevation acute coronary syndrome who were referred from January 2018 to December 2021 to the Apulian STEMI network after an “in-presence” clinical evaluation at a Spoke center or a remote telemedicine-supported assessment. The comparative performance of both approaches has been evaluated by comparing the running diagnosis with the discharge diagnosis.

Results

TEMS and Spoke groups included 470 and 531 patients, respectively. False-positive diagnoses occurred in 21.3% and 35.8% of the TEMS and Spoke patients, respectively (p < 0.001). Spoke group showed a higher number of discharge diagnoses of non-ST elevation myocardial infarction without VHR features (p < 0.001), myocardial infarction with no obstruction of coronary arteries (p = 0.033), and myocarditis (p = 0.007). Overall, the main predictors of false-positive diagnoses were the referral from Spoke center, chronic kidney disease, and ongoing oral anticoagulation.

Conclusions

Telemedicine showed lower false-positive rate compared with an on-site clinical cardiological assessment. This apparently paradoxical result questions the hypothesis of overdiagnosis as the main limitation of telemedicine which conversely reduces time-to-diagnosis and healthcare costs.