Neurology Telemedicine Systems. Telestroke: Expanding the Reach of Coordinated Stroke Care CAHP. October 16, 2012

Transcription

1 Neurology Telemedicine Systems Telestroke: Expanding the Reach of Coordinated Stroke Care CAHP October 16, 2012 Bart M. Demaerschalk, MD, MSc, FRCP(C) Professor of Neurology Director, Cerebrovascular Diseases Center Director, Telestroke & Teleneurology Mayo Clinic Phoenix, Arizona

2 Patient Testimonial On October 8 th, 2011 at my ranch 33 miles from Kingman I suffered a stroke. My wife drove me to KRMC in record time in our old Dodge truck. Admission was immediate, and the ER was running tests. I was totally paralyzed on the left side and could not be understood. Then in rolls the telemedicine equipment, and my wife and I, along with the ER doctors, were face-to-face with one of the top stroke neurologists at Mayo Clinic. The Mayo Clinic doctor examined me, reviewed all of my tests, and then went over them with the ER doctors, my wife, and I. I received TPA, a mega potent clot busting drug, and within 3 hours I was no longer paralyzed and could speak normally. The recovery was so complete, it was like I had never suffered a stroke. I was released the very next day. I credit my miracle and full recovery to The Kingman Regional Medical Center, Mayo Clinic, and to telemedicine technology!

3 State of Emergency Stroke Resources and Care in Rural Arizona 10,000 Arizona residents suffer stroke annually Stroke Centers in Phoenix & Tucson are equipped to provide timely diagnosis & treatment Approx. 20% of urban stroke patients receive emergency treatment Greater than one third of residents live outside major metropolitan communities Thirty-five hospitals exist outside of Phoenix & Tucson Only one has emergency neurological services 24/7 Approx. 2% of rural stroke patients receive emergency treatment Approx. 90% of patients with stroke are transferred by air to urban stroke centers, generally arriving too late for treatment Miley ML, Demaerschalk BM, et al. Telemedicine and e-health 2009

4 Example of Hub & Spoke Telestroke Network

5 Regional Representation of Mayo Clinic Telestroke Network Yellow circles represent Telestroke Sites Yellow circles with red glow represent Telestroke and Teleneurohospitalist Sites

6 Regional Representation of Mayo Clinic Telestroke Network Yellow circles represent Telestroke Sites Yellow circles with red glow represent Telestroke and Teleneurohospitalist Sites

7 National Representation of Mayo Clinic Telestroke Network

8 Telemedicine Solution for Stroke Established in 2007 Hub at Mayo Clinic Hospital, Phoenix Serving nine community spoke hospitals in AZ Telestroke Hotline 24/7/365 1,300 stroke patients have received help, to date Response time of 1 minute Diagnostic accuracy 96% Correctness of treatment recommendation 96% 10-fold increase in thrombolytic administration From 2% to 20% Excellent safety record Morbidity & mortality outcomes similar to stroke centers 60% reduction in costly ground & air ambulance transfers to metropolitan hospitals Planned expansion to 35 spoke hospitals in the state Planned service line expansion to include teleneurohospitalist, tele-eeg (teleepilepsy), and teleconcussion

9 $2 million annually, estimate $50 thousand average annual network cost associated with telestroke per spoke hospital Miley ML, Demaerschalk BM, et al Telemed JE Health 2009

10 Proportion of stroke patients receiving TPA (%) Annual Cost Savings of Increasing Utilization of TPA in Arizona (in thousands of dollars) 2 Baseline with Telestroke AZ 9,360 acute ischemic stroke patients Demaerschalk BM, et al. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke 2005;36:

11 US Cost Effectiveness Analysis Nelson RE et al. Neurology 2011;77:1-1

12 Cost Effectiveness Model

13 US Cost Effectiveness Analysis Nelson RE et al. Neurology 2011;77:1-1

14 Cost Effectiveness Estimates No. of Spoke(s) 90-Day Lifetime 1 $500K/QALY $3.5K/QALY 2 $250K/QALY $3.0K/QALY 3 $175K/QALY $2.5K/QALY 8 $95K/QALY $2.0K/QALY 10 $90K/QALY < $2K/QALY 18 $80K/QALY < $2K/QALY 70 $50K/QALY < $2K/QALY

15 Cost effectiveness of hub & spoke telestroke networks Materials & Methods: Decision analytic model Compare costs and health consequences Rates of consultation, TPA administration, endovascular treatment, spoke-to-hub transfers With and without telestroke network 1 hub and 7 spoke hospitals 5-year time horizon Inputs from Mayo Clinic and Georgia Health Sciences University Effectiveness measured by discharges home & independent Switzer JA, Demaerschalk BM, et al. Abstract submitted to American Academy of Neurology 2012

16 Cost effectiveness of hub & spoke telestroke networks Results: Compared with no network, the telestroke network model resulted in: 45 more patients treated with TPA per year, 20 more endovascular treatments per year, leading to 5.49 more discharges home (independent) per year per 1,000 stroke patients Cost savings realized $6 000 to $ per year Conclusion: In most scenarios, a telestroke network costs less and is more effective than no network Switzer JA, Demaerschalk BM, et al. Abstract presented at American Academy of Neurology 2012

17 Health Economic Analysis Societal Perspective

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19 Incremental cost per patient (discounted) Transfer Rates $1,500 $1,000 Positive values reflect increased costs $500 $0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% -$500 Negative values reflect cost savings -$1,000 -$1,500 -$2,000 -$2,500 -$3,000 Patients transferred to hub hospital (%) (For both patients treated with and without IV thrombolysis)

20 Telestroke Dominates

21 Health Economic Analysis Hospital Perspective

22 Base Case Cost savings from the network perspective

23 Incremental costs/year (discounted) Thousands Results Spoke, hub and network parameters Telestroke network dominated $200 Telestroke network more effective and more costly $ $200 -$400 -$600 -$800 -$1,000 -$1,200 Telestroke network less effective and less costly -$1,400 -$1,600 Incremental home discharges/ year (5-year average for patients presenting in the network) Telestroke network dominant

24 Incremental cost/year (discounted) Thousands Transfer Rates $2,000 $1,000 Positive values reflect increased costs $0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% -$1,000 Negative values reflect cost savings -$2,000 -$3,000 Network Hub Spoke -$4,000 Patients transferred to hub hospital (%) (For both patients treated with and without IV thrombolysis)

25 Barriers to Telemedicine Objective: To determine factors which impede acceptance and maintenance of telemedicine Methods: survey sent 483 individuals representing 63 healthcare institutions Results: 106 respondents representing 22% of invitees and 60% of institutions Top barriers: Insufficient reimbursement, licensing & privileging, cost of technology Rogove HJ, McArthur D, Demaerschalk BM, Vespa PM. Telemedicine and e-health 2012.

26 Telemedicine in US Neurology Departments 18/30 (60%) provide telemedicine 2/3 not providing telemed plan to start Stroke n=14/30 Movement Disorders n=4/30 Neurocritical Care n=4/30 Cognitive, epilepsy, MS, other 28% hub funding 22% federal/state grant funding 17% payment from insurers Reimbursement most frequent barrier George BP et al. The Neurohospitalist 2012

27 Conclusion Telestroke network care is more clinicallyeffective and cost-effective than the current standard emergency care model without telemedicine Reimbursement for telemedicine consultations is inadequate and is impeding progress

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