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Telestroke Is It Ready for Prime Time?

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Presentation on theme: "Telestroke Is It Ready for Prime Time?"— Presentation transcript:

1 Telestroke Is It Ready for Prime Time?
David Wang, D.O., FAHA, FAAN Director, OSF/INI Stroke Network Clinical Associate Professor of Neurology University of Illinois College of Medicine at Peoria

2 Disclosure Statement Dr. Wang is a member of:
Illinois Stroke Task Force. Co-Chair, Illinois Stroke Task Force Telestroke Subcommittee Executive Committee, American Academy of Neurology-Vascular Section Quality Measurement and Reporting Subcommittee, AAN Advisory Committee, American Stroke Association International Operations Committee, American Heart Association Speaker Bureau: Pfizer, Boeringher-Ingelheim,

3 The Scope of the Problem
Stroke Incidence: +61% 700,000 a year, third leading cause of death, leading cause of adult disability. rt-PA needs to be given within 3 hrs, which presents an opportunity to improve patient outcomes and reduce overall costs to the US health system 2. Stroke Incidence US Market, Sources: Sg2 Analysis, 2006.

4 4 Key Elements in the Initial Evaluation and Treatment of a Stroke
ER Emergency room physicians are often reluctant to administer t-PA without the guidance of a neurologist. Radiology Neurology Few have access to a general neurologist Even fewer have access to a highly skilled stroke neurologist Stroke Team Responsible for delivering organized, error-free quality care

5 Not Enough Neurologists
48 million Americans residing in counties that contain no neurologist. American Academy of Neurology Report: 10,038 U.S. Neurologists registered 83.7% were adult Neurologists % had stroke as their practice focus 47% strongly agree and feel comfortable in giving tPA.

6 Hospital Administrator’s Headache
We can’t get anyone (neurologist) to take ED stroke calls. We don’t have any neurology coverage. The closest neurologist is 70 miles away and he has a waiting period of 6 months.

7 Not Enough Radiologists
American College of Radiology: There are about 25,600 post-training diagnostic radiologists in the US 73% of these radiologists work full time Over half of the radiologists surveyed indicated that they were overworked There are not enough Radiologists interpret imaging studies of the stroke patients 24/7 There are even fewer Interventionists that can deliver catheter-based treatment Sunshine JH, et al. Diagnostic Radiologists in Basic Characteristics, Practices, and Issues Related to the Radiologist Shortage. AJR 2002;178:

8 What Do We Have? According to the Hospital Statistics 2002: 4,856 US hospitals reported 85% have emergency departments 65% have medical or surgical intensive care 78% have CT scanner 48% have MRI 80% have ultrasound services 69% have case management 85% have social workers 27% have inpatient physical rehabilitation services 76% have outpatient physical rehabilitation services Facilities and Services in the U.S. Census Divisions and States. Hospital Statistics. Health Forum LLC, an affiliate of the American Hospital Association

9 Can TeleStroke Help? Not enough Neurologists and Radiologists,
TOO MANY STROKES! Telestroke, Hospitals without onsite stroke expertise are provided with the access to stroke centers (stroke expertise) in real time. No distance limitation between the site hospital and the stroke center. What it takes to set up a telestroke network Benefit of telestroke Pros and Cons of Telestroke

10 Telestroke-Technology Involved
Low tech: Telephone consultations Need some tech: Incorporate radiology image transmission High tech: Real time audio and video conferencing via wireless encrypted transmission, or secure landline and transmitting neuro images simultaneously.

11 Hub and Spoke Model, high tech

12 Sources: Sg2 Analysis, 2006. Name of System Description
Stroke-Center Hub and Spoke Model Neuro-critical care specialists based in a Academic or Tertiary Care Medical Center Examples: Partner’s Tele-stroke program, Medical College of Georgia REACH* program Partners Tele-stroke Program Serves 14 hospitals in Massachusetts and provides consultation for AMCs willing to develop a stroke network. Distributed cost model where both the hub and the spoke hospitals share costs associated with tele-stroke. Spoke hospitals pay for videoconferencing equipment ($5,000 to $20,000), annual maintenance fees and a fee per Tele-Stroke Consult ($1,000 each). Hub hospital provides on-site and continuing stroke education, and necessary implementation steps and training sessions for staff. Advantage: Spokes aligning with major stroke center hubs are aligned to provide advanced neurovascular services their patients may need and can market their affiliation to draw patients as referrals. Sources: Sg2 Analysis, 2006.

13 Sources: Sg2 Analysis, 2006. Name of System Description
Physician Hub and Spoke Model Network or center of independent neuro-care specialists, independent of tertiary or Academic Medical Centers provide consultations to surrounding hospitals. Brain Saving Technologies Establishes Neuro-critical Care Centers First one at UMASS Memorial Medical Center staffed by stroke specialists. Currently serves five hospitals in Massachusetts and Virtua Health System in New Jersey. Hospitals pay a fixed yearly price. As an example a 300 bed hospital the fee is around $216K plus upstream costs for technology. Advantage: Organizations that do not have the stroke volumes to justify the cost of the video technology can leverage it for other telemedicine services. Sources: Sg2 Analysis, 2006.

14 Tele-Stroke Technology Providors
BF-Technologies Sells a bi-directional audio and video system (AccessVideo™ $24,000) Charges a yearly maintenance fee of $6,000. System provides site-independent access error-free HIPPA compliance encryption, remote pan/tilt/zoom, and full audio/video session recording. University of California San Diego has such set-up Stroke Team Remote Evaluation Using a Digital Observation (STRokE DOC). Courtesy of Sg2

15 InTouch Health® Mobile robot (RP-7 Remote Presence Robotic System) that allows a remote physician to guide the robot to the patient’s bedside, and evaluate the patient through bi-directional video and audio communications. A robot costs $120,000 to buy, or $4,000 a month to rent. The Michigan Stroke Network which includes 21 Michigan hospitals and spearheaded by St. Joseph Mercy Oakland Hospital is an example of a stroke network using robotic technology. Courtesy of Sg2


17 Where Is the Funding? States initiating reimbursement for telemedicine: NY, CO, GA, FL, OK Federal Funding: Grants more likely, and it is usually one time deal Some stroke networks have been funded by tobacco taxes (Colorado $185,000),or grants from the State’s Stroke Center Act (New Jersey $390,000) Share the cost: Per use based or flat fee between the hub and spokes Others: Patient revenue, hospital operating budgets, Philanthropy. Paying a yearly fee: Brain Saving Technologies $216K per year

18 TeleStroke-PROs The cost is flexible, depending on the system used
It can be wireless, nearly real time with broad band Extend stroke care expertise into rural and underserved areas. It is time saving and efficient. Doc-Doc, Doc-patient interaction allowed at distance Multifunctional: films, labs, medical records, pathology report Provides rapid access to specialized interventions through initiation of inter-hospital transfers and improve in basic on-site stroke therapy. It has demonstrated improved use of rt-PA. It may improve enrollment in acute stroke trials.

19 Impact on Stroke Care Videoconferencing by off-site stroke neurologist provides accurate assessment of the patient’s physical condition and neuroimaging studies Tele-stroke can maximize use of life saving therapies: A rural hospital that had not used tPA in 2yrs increased tPA administration to 5.6% with the Partners Tele-Stroke Network Houston: 0.8% use of rt-PA improved to 4.3% Improves hospital standing in the community by providing leading treatments. Reduces mortality rate by identifying patients who need to be transferred for advanced care. Sources: Sg2 Analysis, 2006.

20 Impact in Rate of Thrombolysis after Implementation of Telestroke Network
The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care. Telemedicine support to 12 community hospitals without on-site stroke specialists. 3/ / ,606 entries divided in two phases: pre-telemedicine (N= 933) and post-telemedicine (N=1,673). Outside of the three-hour-window was the most common contraindication for thrombolytisis (52.3%). 143 patients received thrombolytics, with 35 interventions prior to starting telemedicine and 108 after. Thrombolysis rate prior to telemedicine was 3.8% and after 6.5% (p=0.004). Incorrect treatment decisions happened 10 times (0.39%), with 4 (0.43%) pre vs. 6 (0.36%) post telemedicine (p=0.78). There were no statistically significant differences in mortality (15.9% pre vs. 9.2% post; p=0.23) or good outcome (17.1% pre vs. 15.8% post; p=0.84). S-ICH happened in six patients (4 [9.8%] pre vs. 2 [1.9%] post telemedicine). CONCLUSIONS: Telestroke implementation increased rate of thrombolytic use in remote hospitals within the telemedicine network.


22 Telestroke-Cons Price HIPPA, patient confidentiality
Can be complicated to use and maintain Lack of reimbursement will hinder widespread adaptation of its use. Is a patient's brain scan clearly readable over the system? Are onsite physicians able to adequately care for the patient after the medication is given? Reimbursement and liability issues pending resolved

23 The Ideal Set-up Affordable Portable User friendly
Can have a mixture of high-tech and low-tech type of network Low maintenance Maintain confidentiality No one type or size of telestroke system that will fit all situations. Type of clinical applications and volume of consultations determine the characteristics and costs of the appropriate systems.


25 Six Current Centers that Function as CSCs and uses different Telestroke Equipment
How does this currently play out in reality? I’m going to go through a whirlwind tour of six centers in a diversity of settings – large cities, smaller cities, and rural communities and share their systems of care for acute tPA delivery. I am focusing on acute reperfusion treatment delivery as this is where we see a particularly diverse and complex set of relationships between CSCs, PSCs, and community centers. 50 miles Transfer hospital Telemedicine hospital Our hospital 25

26 Example #1: Greater Cincinnati/Northern Kentucky Stroke Network
Acute Team Based at Univ of Cincinnati (UC) 3 Emergency physicians 7 Vascular neurologists 4 Neurointerventionalists 6 Acute Coordinators 15 Hospitals 1 University UC) 3 Teaching 11 Community 15 local hospitals, including 4 PSCs EMS brings pts to nearest hospital UC Stroke team MD drives to all local hospitals Encourage pre-notification (prior to CT completion) Study coordinator comes if possible trial candidate Additional ~10 regional hospitals Drip and ship by phone assessment Starting with the example I know best…. 2.1 million population for metropolitan area; About 30 miles between farthest hospitals; Crosses state lines 26

27 Example #2: Saint Luke’s Brain and Stroke Institute – Kansas City Stroke Referral Network
Over 80 hospitals, including 4 PSCs PSCs refer for IA tx or IV tPA guidance Phone consultations; no fee for 24/7 support Treat ~30% of cases called in Threshold for transfer Post IV rtPA care For IA therapies Weekly education in region by MDs and RNs 2.1 million KC metro; >100 mile radius

28 Example #3: University of Texas-Houston Stroke Network
Currently: About 40 calls/mo; 1-2 per 24 hr period; treat 25% 43% daytime, 36% evening, 21% at night 60-70% of calls are stroke-related About 6 TPA treatments/mo Changing climate Increasing # of pts take to local PSCs rather than MHH Decreasing pt access to research and IA therapies at MHH Concern for decreasing rates of rtPA use at low-volume ctrs Six UT Dept of Neurology faculty Memorial Herman Hospital (MHH) 22+ hospitals via telemedicine Two systems Additional regional hospitals by phone Drip and Ship 50 miles Transfer hospital Telemedicine hospital Our hospital Houston metropolitan population of 5.7 million; 2 IA centers within three blocks of hub

29 Example #4: UCSD Stroke Network
STRokE DOC network (trial on hold) UCSD: 4 telemedicine hospitals miles away Mayo Scottsdale: 2 Telemedicine hospitals 28% telemedicine rt-PA during trial period More accurate rtPA decision-making with video, comparable safety and outcomes by phone Acute Team Based at UC San Diego (UCSD) 6 Vascular neurologists 4 Coordinators 2 Emergency Physicians 4 Neuro-Interventionalists 10 Hospitals 1 University (2 Centers) 4 Community (physical coverage) 3-4 Remote (phone /telemedicine) 15% treatment rate overall 6.50 rt-PA treatments per month 2.75 rt-PA treatments per < 2 hours from symptom onset How many of you are from the Cincinnati Metropolitan Region, if ANY? >100 My utopia of stroke care, vs reality in mos of country Neurologists didn’t sign up to wake up at night 12 miles to farthest hospital (drive) 150 miles to farthest hospital (telephone) 350 miles to farthest hospital (telemedicine) San Diego metropolitan population 3 million 29

30 Example #5: Med Coll of Georgia (MCG) REACH Telestroke Network
6 MDs 5 neurologists 1 EM physician 15 hospitals 10 rural (<75-bed) 5 larger community ( beds) 10 smaller rural hospitals ( miles) No 24-hr radiology; drip and ship 5 larger community hospitals Two PSCs, but lack 24/7 stroke coverage Telestroke coverage for a fee “Treat and keep” at local hospital (DRG 559) Transfer for higher level of care Decreasing 24/7 local neurology coverage in region and potential for REACH being at capacity ~200 miles

31 Example #6: OSF/INI Stroke Network
Telestroke by the JEMS System, projecting live video to your cell phone. 4 helicopters for transport 10/09-9/11: 875 transfers 179 drip and ship cases from 30 hospitals TPA administration rate:20%

32 The Challenges Facing Telemedicine
Who regulates the existing telemedicine structure? The authority of local and regional providers in developing telemedicine. When it becomes Web-based, what will happen to the traditional relationships that exist between a doctor and a patient? It may be an investment that may not have clear financial return. Credentialing among spoke hospitals and cross the states The Stark law of preventing enticement JD Linkous, MD Net Guide 11/06

33 A Look at the Budget for a Telestroke Network
One new rural spoke hospital needs about $46,000 ( $10,000 -$20,000) per year dependent upon the size of hospital, volume of stroke consultations, and sophistication of telemedicine equipment selected. The start-up and first year of operation cost for a multi-hub network serving 35 rural spoke hospitals was $2.5 million. Costs include: neurology, personnel, coordinators, managers, information technologists, administrators, telemedicine platform equipment, institute supplies, laptop cameras, headsets with microphones, broadband wireless cards, efax subscriptions, travel expenses, training, and overhead.

34 So, Does Telestroke Save Money?
Compared two-way audio video technology to usual care A decision analytic model was developed for both 90-days and lifetime horizons. Model inputs included both costs and clinical consequences. Quality adjusted life years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs). In the base case analysis, compared to usual care, telestroke resulted in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon. Telestroke appeared cost-effective REALLY?

35 So, Does Telestroke Save Money?
A network model: -more patients treated with IV thrombolysis -more patients transferred for endovascular management -more patients discharged home independently. The telestroke network costs less, overall, and was more effective than no network. With increased spoke to hub transfer rates, the hub experiences greater cost savings while the spokes bear higher costs. When reducing spoke to hub transfer rates, the spokes experience greater cost savings while the hub bears higher costs.

36 So, Does Telestroke Save Money?
The answers to this question are: Patients may get better care at the cost of the institution that establishes and runs telemedicine Institutions are not being paid adequately to run telestroke network Health economic research is needed to develop viable and sustainable business plans.


38 The Near Future

39 Conclusion Telemedicine Can solve the problem of access to specialty services Currently there is no set rules to regulate telemedicine Telemedicine improves TPA use in stroke patients in rural and remote ERs Technologically it will be cheaper to set it up in the near future To staff and support telemedicine is not cheap. Telemedicine may not have financial benefit to the institution that runs it

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