1. Telestroke Models of collaboration of care Salvador Cruz-Flores, MD Saint Louis University

2. Objectives To understand: Current state of stroke care Rationale for telestroke System models of “remote presence”

3. Current state of stroke care 2 nd leading cause of death worldwide and 3 rd leading cause in US Major contributor to adult disability: 15-30% permanently disabled Economic burden: $65.5 billion n US in 2008 87% of stroke mortality occurs in low- and middle-income regions –access to care not readily available Strikes all ages, genders, race and ethnic groups

4. Stroke readiness

6. Current state of stroke care Two thirds of stroke patients arrive by EMS Limited EMS in rural areas Reluctance to use tPA in absence of stroke expertise

7. Current state of stroke care 4 neurologists/100,000 people –Fewer with stroke expertise 385 interventional neuroradiologists in US in 238 hospitals, 45 states Litigation and liability –Greatest risk is from failure to document reasons for withholding therapy and not from injury related to therapy <5% (perhaps <2%) stroke patients receive tPA

8. Rural Hospitals 5759 Hospitals in the US –4919 community Hospitals –2003 Rural Hospitals (AHA statistics 2006) –1464 Community hospitals in a network –2669 hospitals in a system

9. tPA usage MEDPAR database –64% of US hospitals did not reat a single medicare patient with tPA over a 2 years period –Kleindorfer D, Stroke 2009 presented at ISC

10. Why the limited usage 40% od ER physicians reluctant to use tPA In 2006-2007 only 32 fellows in approved vascular neurology fellowships in the US Many neurologists are abandoning emergency room call

12. Stroke Systems Models of Care Stroke call with in person response to ER Telephone drip and ship Helicopter ship and drip Telestroke Telestroke with helicopter

13. Rationale for telestroke Access to stroke consultation remotely Reliability –Neurological exam compared to face to face exam –NIHSS –Teleradiology Thrombolysis via telestroke appears safe Decision making more accurate Rate of tPA treated patients higher than rates in community hospitals

14. REACH

16. Stroke systems of care Regionalization Levels of care –Comprehensive stroke center –Primary stroke center Stroke center capability –Stroke unit –Evidence based stroke management –Collection of stroke quality measures –Clinical and educational collaborations between hubs and spoke facilities –QI If no capability= transfer agreements Partial capability= drip and ship

17. Stroke system models

18. Telestroke models Regionalization of care Hub and Spoke Models Frontier/Rural Rural-Urban Suburban-Urban Urban Underserved

19. The Alaska Native Stroke Registry: A Frontier/Rural Health Delivery Model

20. Alaska in Relation to the “Lower” 48 States 1 2 3 4 5 6 1=Artic (polar bears/walrus) 2=Western 3=Southwestern (Aleutians) 4=Interior (Fairbanks) 5=Southcentral (Anchorage) 6=Southeastern (panhandle) Population: 663,661 Size: 571,951 sq. miles

21. Hierarchy of Care in Alaska 1.Villages without health aids 2.Villages with health aids (n=500 for 170 remote villages) 3.Village with subregional clinic (midlevel practitioners) 4.6 regional hospitals (inpatient, outpatient and ER services but only 1 has a CT scan) and FPs 5.1 referral/specialty hospital: Alaska Native Medical Center, Anchorage, Alaska An estimated 58% of individuals live in communities without regional hospitals (villages may contain <200 persons) Source: Alaskan Natiave Tribal Health Consortium, 2003 FP= Family Practitioner

22. 1 Hubs and Spokes: 12 regions and 6 tribal hubs Primary Linkage: Telephone and Fax

23. Challenges of frontier/rural model Slow feed into hubs. Standard stroke care may never be given (e.g., thombolytic therapy) Air travel to the spokes and other remote areas is costly and time consuming Access to specialty care may be limited and costly

24. Rural US Stroke Model Critical Access Hospitals

25. REACH

26. Rural Areas May Lack Specialty Care Single hub and spoke system and then upscale to multiple hub and spoke systems Courtesy of David Hess, MD REACH Telemedicine System

27. Telestroke systems for neurological emergencies Intracerebral hemorrhage Traumatic brain injury Post cardiac arrest Spinal cord injury Status epilepticus Subarachnoid hemorrhage Other disease states beyond neurology

28. Suburban urban model Comprehensive stroke center Primary stroke center Community hospital

31. Thrombolysis by telephone

32. Thrombolysis by phone OSF stroke network Peoria Il St. Lukes’s Stroke Center KC –53/142 tpa treated started in referring hospitals University of Kentucky Limited data on safety and efficacy

33. tPA plus Bridging IV tPA + IA tPA Mechanical embolectomy Sonotrhombolysis Participation in clinical trials

35. Potential models with telestroke Ship and drip Drip and ship Drip and keep Drip, ship and randomize Drip, randomize and ship Drip, randomize, and keep

36. Challenges to Medical Outsourcing Telemedicine Information privacy (HIPAA regulations) Infrastructure funding and operation costs Regulatory and billing compliance Malpractice and liability (uncharted territory regarding what constitutes telemedicine malpractice and standard of care) Physician licensure/credentialing Informed consent needed? Measuring and ensuring quality of care Source: Singh SN, Wachter RM. NEJM 2008; 358: 15; 1622-27

37. Missouri

38. Summary Stroke affects underserved areas Telemedicine can breach that gap Regionalization and time critical diagnosis nature favor Hub and Spoke model Air transport may continue to be critical for “frontier” regions Regulatory changes (with regards to stroke care) will probably force adoption of telestroke systems and early deployment of air transport Video audio teleconferencing is the current recommended mode Safety of teleconsultation via phone and teleradiology Challenges are many but regulatory/liability, financial/funding and confidentiality remain as significant issues Research on efficacy and safety is needed

39. Recommendations for implementation of telemedicine within stroke systems of care. Schwamm LH, Audelbert HJ, Amarenco P et al. Stroke 2009 (DOI10.116/StrokeAHA.109.192361 A review of the evidence for the use of telemedicine with stroke systems of care. Schwamm LH, Holloway RG, Amarenco P, et al. Stroke 2009. (DOI10.1161/StrokeAHA.109.192360)