Telemedicine network associated with lower 90-day mortality and care needs in rural acute neurological disordersCould a 24/7 telemedicine network help rural hospitals save lives after a stroke or brain injury?

Frontiers in Medicine Published April 19, 2026 Study authors: Janina Behrens, Tobias Kurth, Malgorzata Kotlarz-Böttcher, Anselm Angermaier, Sarah Theen, Rohat Ger… DOI ↗ Editorial oversight: Dr. Ji-eun Park, MD · Brain, Mind & Pain

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Key Takeaway

Consider that this observational study associates a rural telemedicine network with improved 90-day outcomes for acute neurological disorders, but causation is not proven.

This was a prospective pre- and post-implementation cohort study using claims data from 11 ANNOTeM network hospitals and 11 matched non-network hospitals in rural northeast Germany. The population consisted of consecutively hospitalized adults with ICD-10 coded acute neurological disorders. The intervention was a digitally enabled hub-and-spoke telemedicine network providing 24/7 remote expertise, standardized operating procedures, and digital quality management, compared to matched hospitals without the network.

The primary outcome was a composite of 90-day mortality and new need for outpatient or nursing home care. In ANNOTeM hospitals, the primary composite outcome rate decreased to 33.8% vs. 35.9% in the pre-implementation period (unadjusted absolute difference: −2.1%; adjusted absolute difference: −3.2%). The adjusted hazard ratio was 0.89 (95% CI: 0.79–0.99). In control hospitals, the rate was 40.7% vs. 42.5% (aHR 1.04, 95% CI: 0.85–1.15), showing no improvement.

Mean 90-day total costs per patient in ANNOTeM hospitals rose modestly from €11,938 to €12,252 (+2.6%, non-significant). The cost per avoided adverse composite outcome was €14,968 (unadjusted). Safety data, including adverse events, serious adverse events, discontinuations, and tolerability, were not reported.

Key limitations include the observational design, which cannot establish causation, and the use of claims data. The study was limited to rural northeast Germany, and long-term outcomes beyond 90 days were not assessed. Practice relevance supports the economic sustainability and transformative potential of network-based telemedicine for acute neurological care in underserved rural regions, but findings may not generalize to non-rural settings.

When someone in a rural town has a sudden stroke or another acute neurological emergency, getting specialist help quickly can be the difference between going home or needing lifelong care. This study looked at whether a digital hub-and-spoke telemedicine network—offering 24/7 remote expertise, standard procedures, and digital quality checks—made a difference for these patients.

The researchers compared 11 hospitals using the ANNOTeM telemedicine network with 11 similar rural hospitals that did not. They followed adults hospitalized with acute neurological disorders for 90 days. The main finding was that the combined rate of death or new need for nursing home or outpatient care was lower in the network hospitals after implementation (33.8% vs. 35.9% before, and 40.7% vs. 42.5% in control hospitals). The adjusted analysis suggested a modest benefit, with a 95% confidence interval that just included no effect.

Costs per patient in the network hospitals rose slightly, and the cost per avoided adverse outcome was about €14,968. No safety events were reported, but the study did not track them specifically. This was an observational study using claims data, so it can show an association but not prove the network caused the improvement. The findings may not apply to non-rural settings, and longer-term outcomes beyond 90 days are unknown.

What this means for you:

A rural telemedicine network was linked to slightly better outcomes after acute neurological emergencies, but it's not proof it caused the change.

Study Details

Study typeCohort

EvidenceLevel 3

PublishedApr 2026

View Original Abstract ↓

Expert neurological care in rural areas remains a major challenge and contributes to disparities in outcomes after acute neurological emergencies. To address this gap, the ANNOTeM project established a comprehensive, digitally enabled “hub-and-spoke” telemedicine network connecting academic neurology centers with regional hospitals in northeast Germany, providing 24/7 remote expertise, standardized operating procedures, and digital quality management. This prospective pre and post implementation study used statutory health insurance claims to compare patient outcomes and costs for acute neurological emergencies across 11 ANNOTeM network hospitals vs. 11 matched non-network hospitals (all hospitals were localized in rural regions). The analysis included all consecutively hospitalized adults with ICD-10 coded acute neurological disorders. The primary clinical endpoint was the composite of 90-day mortality, new need for outpatient or nursing home care. Health economic evaluation included direct medical, non-medical, and indirect costs from the insurer's perspective. Following network implementation, the rate of the primary outcome decreased in ANNOTeM hospitals (33.8% vs. 35.9%; unadjusted absolute difference: −2.1%; adjusted absolute difference: −3.2%; aHR 0.89, 95% CI: 0.79–0.99), with no improvement in control hospitals (40.7% vs. 42.5%; aHR 1.04, 95% CI: 0.85–1.15). Mean 90-day total costs per patient rose modestly from €11,938 to €12,252 (+2.6%, non-significant). Non-network hospitals showed a similar non-significant cost increase. The cost per avoided adverse composite outcome was €14,968 (unadjusted). Implementing a digitally integrated teleneurology network was associated with improved patient outcomes without substantial increases in per-patient costs. These results support the economic sustainability and transformative potential of innovative, network-based telemedicine systems for acute neurological care in underserved, rural regions.

Telemedicine network associated with lower 90-day mortality and care needs in rural acute neurological disordersCould a 24/7 telemedicine network help rural hospitals save lives after a stroke or brain injury?

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Telemedicine network associated with lower 90-day mortality and care needs in rural acute neurological disordersCould a 24/7 telemedicine network help rural hospitals save lives after a stroke or brain injury?

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