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, FAANDirector, OSF/INI Stroke NetworkClinical Associate Professor of NeurologyUniversity 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 SubcommitteeExecutive Committee, American Academy of Neurology-Vascular SectionQuality Measurement and Reporting Subcommittee, AANAdvisory Committee, American Stroke AssociationInternational Operations Committee, American Heart AssociationSpeaker 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.RadiologyNeurology Few have access to a general neurologist Even fewer have access to a highly skilled stroke neurologistStroke 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 overworkedThere are not enough Radiologists interpret imaging studies of the stroke patients 24/7There are even fewer Interventionists that can deliver catheter-based treatmentSunshine 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 servicesFacilities 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 networkBenefit of telestrokePros and Cons of Telestroke
10 Telestroke-Technology Involved Low tech: Telephone consultationsNeed some tech: Incorporate radiology image transmissionHigh tech: Real time audio and video conferencing via wireless encrypted transmission, or secure landline and transmitting neuro images simultaneously.
12 Sources: Sg2 Analysis, 2006. Name of System Description Stroke-Center Hub and Spoke ModelNeuro-critical care specialists based in a Academic or Tertiary Care Medical CenterExamples: Partner’s Tele-stroke program, Medical College of Georgia REACH* programPartners Tele-stroke ProgramServes 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 ModelNetwork or center of independent neuro-care specialists, independent of tertiary or Academic Medical Centers provide consultations to surrounding hospitals.Brain Saving TechnologiesEstablishes Neuro-critical Care CentersFirst 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-TechnologiesSells 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, OKFederal Funding: Grants more likely, and it is usually one time dealSome 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 spokesOthers: 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 bandExtend stroke care expertise into rural and underserved areas.It is time saving and efficient. Doc-Doc, Doc-patient interaction allowed at distanceMultifunctional: films, labs, medical records, pathology reportProvides 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 CareVideoconferencing by off-site stroke neurologist provides accurate assessment of the patient’s physical condition and neuroimaging studiesTele-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 NetworkHouston: 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 maintainLack 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 networkLow maintenanceMaintain confidentialityNo 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 milesTransfer hospitalTelemedicine hospitalOur hospital25
26 Example #1: Greater Cincinnati/Northern Kentucky Stroke Network Acute TeamBased at Univ of Cincinnati (UC)3 Emergency physicians7 Vascular neurologists4 Neurointerventionalists6 Acute Coordinators15 Hospitals1 University UC)3 Teaching11 Community15 local hospitals, including 4 PSCsEMS brings pts to nearest hospitalUC Stroke team MD drives to all local hospitalsEncourage pre-notification (prior to CT completion)Study coordinator comes if possible trial candidateAdditional ~10 regional hospitalsDrip and ship by phone assessmentStarting with the example I know best….2.1 million population for metropolitan area;About 30 miles between farthest hospitals;Crosses state lines26
27 Example #2: Saint Luke’s Brain and Stroke Institute – Kansas City Stroke Referral Network Over 80 hospitals, including 4 PSCsPSCs refer for IA tx or IV tPA guidancePhone consultations; no fee for 24/7 supportTreat ~30% of cases called inThreshold for transferPost IV rtPA careFor IA therapiesWeekly education in region by MDs and RNs2.1 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 night60-70% of calls are stroke-relatedAbout 6 TPA treatments/moChanging climateIncreasing # of pts take to local PSCs rather than MHHDecreasing pt access to research and IA therapies at MHHConcern for decreasing rates of rtPA use at low-volume ctrsSix UT Dept of Neurology facultyMemorial Herman Hospital (MHH)22+ hospitals via telemedicineTwo systemsAdditional regional hospitals by phoneDrip and Ship50 milesTransfer hospitalTelemedicine hospitalOur hospitalHouston 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 awayMayo Scottsdale:2 Telemedicine hospitals28% telemedicine rt-PA during trial periodMore accurate rtPA decision-making with video, comparable safety and outcomes by phoneAcute TeamBased at UC San Diego (UCSD)6 Vascular neurologists4 Coordinators2 Emergency Physicians4 Neuro-Interventionalists10 Hospitals1 University (2 Centers)4 Community(physical coverage)3-4 Remote(phone /telemedicine)15% treatment rate overall6.50 rt-PA treatments per month2.75 rt-PA treatments per < 2 hours from symptom onsetHow many of you are from the Cincinnati Metropolitan Region, if ANY?>100My utopia of stroke care, vs reality in mos of countryNeurologists didn’t sign up to wake up at night12 miles to farthest hospital (drive)150 miles to farthest hospital (telephone)350 miles to farthest hospital (telemedicine)San Diego metropolitan population 3 million29
30 Example #5: Med Coll of Georgia (MCG) REACH Telestroke Network 6 MDs5 neurologists1 EM physician15 hospitals10 rural (<75-bed)5 larger community ( beds)10 smaller rural hospitals ( miles)No 24-hr radiology; drip and ship5 larger community hospitalsTwo PSCs, but lack 24/7 stroke coverageTelestroke coverage for a fee“Treat and keep” at local hospital (DRG 559)Transfer for higher level of careDecreasing 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 transport10/09-9/11:875 transfers179 drip and ship cases from 30 hospitalsTPA 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 statesThe Stark law of preventing enticementJD 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 careA 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 networkHealth economic research is needed to develop viable and sustainable business plans.
39 ConclusionTelemedicine Can solve the problem of access to specialty servicesCurrently there is no set rules to regulate telemedicineTelemedicine improves TPA use in stroke patients in rural and remote ERsTechnologically it will be cheaper to set it up in the near futureTo staff and support telemedicine is not cheap.Telemedicine may not have financial benefit to the institution that runs it