Telestroke Models of collaboration of care

1. TelestrokeModels 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 • 2nd leading cause of death worldwide and 3rd 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 modelsRegionalization 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 4 2 5 3 6 Population: 663,661 Size: 571,951 sq. miles 1=Artic (polar bears/walrus) 2=Western 3=Southwestern (Aleutians) 4=Interior (Fairbanks) 5=Southcentral (Anchorage) 6=Southeastern (panhandle)

21. 1 Hubs and Spokes: 12 regions and 6 tribal hubs Primary Linkage: Telephone and Fax

22. 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

23. Rural US Stroke Model Critical Access Hospitals

24. REACH

25. 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

26. Suburban urbanmodel Comprehensive stroke center Primary stroke center Primary stroke center Primary stroke center Community hospital Community hospital Community hospital Community hospital Community hospital Community hospital

29. Thrombolysis by telephone

30. 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

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

33. 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

34. Challenges to Medical OutsourcingTelemedicine • 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

35. Missouri

36. 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

37. 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)