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The State of Stroke In Arizona

The State of Stroke In Arizona. Dr. Timothy Ingall Associate Professor of Neurology Cerebrovascular Diseases Center Mayo Clinic Hospital. Stroke Programs in Arizona. Operation Stroke. A nationwide American Stroke Association initiative implemented in 1999. Two major goals:

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The State of Stroke In Arizona

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  1. The State of Stroke In Arizona Dr. Timothy Ingall Associate Professor of Neurology Cerebrovascular Diseases Center Mayo Clinic Hospital

  2. Stroke Programs in Arizona

  3. Operation Stroke • A nationwide American Stroke Association initiative implemented in 1999. • Two major goals: • Reorganize stroke services to provide better acute stroke care across the USA. • Implement OS in the largest 125 metropolitan areas by 2003.

  4. Primary Stroke Center Initiative • A collaborative effort between Operation Stroke and Arizona Emergency Medicine Systems (AEMS ) • Regular meetings between members of the OS Executive Committee and the AEMS Categorization Committee

  5. Primary Stroke Center Initiative - Timeline • 2001-2002 • Stroke center surveys conducted by both OS and AEMS based on modified PSC criteria • Help provided to hospitals that needed assistance to meet PSC criteria

  6. Primary Stroke Center Initiative • April 2003 • Site visits commence for hospitals requesting to be included in the AEMS PSC Matrix

  7. Primary Stroke Center Initiative September 2003 – proposal presented to AEMS Board to implement a limited PSC Matrix involving six hospitals.

  8. Phoenix Primary Stroke Center Initiative Currently • Eight hospitals classified as Primary Stroke Centers based on the local certification process.

  9. Phoenix Primary Stroke Center Matrix Arrowhead Mayo Hospital Del Webb BNI -- St. Joseph’s Boswell SMH Osborn Banner Thunderbird Banner Good Samaritan

  10. Phoenix Stroke Initiative -Objectives • Improve public awareness of stroke symptoms and the need to call 911 if someone develops symptoms of a stroke. • Improve EMS delivery of acute stroke evaluation and transportation utilizing the Phoenix Primary Stroke Center matrix. • Increase the number of Joint Commission certified Primary Stroke Centers in Phoenix. • Increase the number of stroke survivors receiving stroke rehabilitation.

  11. Arizona Cardiovascular Disease State Plan

  12. Cardiac disease and Stroke in AZ • 240,000 Arizonans living with heart disease. • 150,000Arizonans living with stroke. • Cardiac disease and stroke cost Arizona more than 2.5 billion dollars per year.

  13. State Plan Vision and Mission • Vision • Reduce death and disability from Cardiovascular Disease in Arizona • Mission • Reduce death and disability associated with all cardiovascular diseases, particularly heart disease and stroke, using the most efficient, cost-effective and evidence-based strategies available.

  14. Long Term Objectives • Reduce the number of deaths related to heart disease by the year 2020 • Reduce the number of stroke deaths in Arizona by 20 percent by 2010. • Increase the number of people who are aware of the signs and symptoms of a heart attack and a stroke and the importance of seeking immediate medical attention

  15. Long Term Objectives • Increase the number of Arizonans who have their high blood pressure under control by 25%. • Increase the number of Arizonans who have their high cholesterol under control by 25%.

  16. Long Term Objectives • Promote cardiovascular health and prevent heart disease and stroke through interventions in multiple settings, for all age groups, and for the whole population, especially high risk populations.

  17. 2005-2008 AZ CV State Plan Activities • Steering Committee Meeting created to establish priorities. • Statewide CVD Coalition created.

  18. CVD Coalition Workgroups • Prevention • Emergency Response • Healthcare • Rehabilitation • Surveillance • Government Relations/Advocacy • Health Disparities

  19. AZ CV Disease State PlanHealthcare Plan • Establish a state wide network for providing care to acute stroke patients that matches the network of care developed for patients with acute cardiac problems • Implement a telemedicine program – STARR (Stroke Telemedicine for Arizona Rural Residents)

  20. Stroke Telemedicine

  21. Telemedicine Studies: • Frequent Use: tele- medicine for stroke1 tele- pathology tele- critical care tele- cardiology2 tele- dermatology tele- rheumatology tele- psychiatry tele- surgery tele- neurosurgery tele- trauma3 tele- education tele- correctional care • Multiple Studies: ***reliability*** well established proof of concept various systems/ techniques ______________ 1Meyer et al. Neurology. 2005;64:1058-1060. 2Sable et al. Pediatrics. 2002; 109. 3Rogers et al. J. Trauma. 2001; 51: 1037-1041.

  22. Telemedicine: Background Roine, Ohinmaa & Hailey, 2001: Review • 1124 articles • 50 reviewed (assessment studies) • 6 randomized controlled trials: • - procedures sometimes not described • - outcomes sometimes vague • - few economic analyses • - ? no clinical change or $ saved • Results: • Evidence for effectiveness is lacking ◄ ______________ Roine et al.. Canadian Medical Association Journal. 2001. 165:765-771.

  23. STRokE DOC: RCT Telephone VS Telemedicine *rt-PA = 24% Trial Completed Manuscript in press

  24. Optimizing Stroke Care Through Telemedicine Challenge: Stroke centers provide quality stroke care but have limited reach Telemedicine • Well-established mechanism of providing specialized care beyond a hospital’s physical confines • Uses technology to connect patient and physician with a remote specialist • Telephone • Teleradiology • Videoconferencing • The use of telemedicine for stroke care, termed “Telestroke”, now typically involves videoconferencing Levine and McConnochie. Neurology. 2007;69:819-820. Meyer et al. Neurology. 2005;64:1058-1060. LaMonte et al. Stroke. 2003;34:725-728

  25. Telestroke Facilitates Quality Care Potential benefits of telestroke • Increased rate of accurate assessment and appropriate treatment • Ability to provide acute treatment to patients in remote areas • Improved outcomes, reduced morbidity and mortality • Increased comfort in the administration of tPA • Greater opportunity for medical support and back-up • Reduced incidence of protocol violations • Equal access to acute stroke care in a variety of settings Levine and McConnochie. Neurology. 2007;69:819-820. Meyer et al. Neurology. 2005;64:1058-1060. LaMonte et al. Stroke. 2003;34:725-728.

  26. AHA/ASA Guidelines Support Implementation of Telestroke in Rural Areas “Telemedicine can be an effective method to provide expert stroke care to patients located in rural areas. Additional research and experience on the usefulness of telemedicine are encouraged.” Adams at al. Stroke. 2007;38(5):1655-1711

  27. Telestroke: Real-time Videoconferencing Enables Efficient Patient Assessment Video expands and improves upon consultation by allowing… • Visualization and interaction with patient for more accurate assessment • Ability to obtain a valid NIHSS score • Ability to view a CT scan in real time for reliable diagnosis • Sharing patient records with remote physician Vaishnav. Expert Rev Neurother. 2007;7:913-914. Shafqat. Stroke. 1999;30:2141-2145

  28. Key Trends Driving Telestroke Implementation Physicians Hospitals • Increasing demand for • stroke neurologists • Increasing involvement of ED • physicians in stroke care • Increasing importance of • quality initiatives • Increasing competition • Limited resources Telestroke Technology Community • Improving bandwidth/ • communications • Wireless capabilities • Smaller devices/PDA • Increasing national and local recognition that stroke is under-treated • Support for telemedicine networks through federal and state grants

  29. Telestroke Systems Are Customizable Configurations may include: • Desktop PC or laptop • High speed internet access • Camera on monitor directed at patient and remote physician • IP/ISDN connection for videoconferencing • Ability to view a CT scan in real time • Data encryption supports HIPAA compliance Vaishnav. Expert Rev Neurother. 2007;7:913-914. Shafqat. Stroke. 1999;30:2141-2145

  30. “Third Party Consult” Model Traditional “Hub and Spoke” Model Spoke Spoke Tertiary Hospital Spoke Spoke Hub Neurologist Spoke Spoke Neurologist Spoke Spoke • Spoke contracts with third party provider • Neurologist employed by third party • Spoke develops referral relationship with tertiary hospital for more complex cases • Hub Hospital: designated stroke center • Spoke Hospitals: lack 24/7 neurology support Different Models of Telestroke Third Party Consult

  31. Increasing and Expanding Telestroke Networks in Urban and Rural Settings Colorado Neurological Stroke Center Michigan Stroke Network Renown Institute for Neuroscience Utah Telehealth Network University of Pittsburgh Medical Center University of California Los Angeles The Maryland Brain Attack Center Partners TeleStroke Center University of California San Diego Mayo Clinic STARR Medical College of Georgia Remote Evaluation of Acute Ischemic Stroke (REACH) University of Texas Health Sciences Center

  32. STRokE DOC Arizona Deployment Phase One 190 miles Mayo Clinic Hospital Stroke Center 184 miles

  33. STRokE DOC AZ TRIALStroke Team Remote Evaluation Using a Digital Observation CameraThe Initial Mayo Experience • Hotline activated on 68 occasions as of 7/31/08 • 40 patients enrolled into study randomized to either telephone only or video/audio consult • 35% of consults result in thrombolysis treatment

  34. STARRStroke Telemedicine for Arizona Rural Residents • Kingman RMC • Yuma RMC • Chinle • Verde Valley • Northern AZ VA • La Paz • Cobre Valley • Carondalet • Sierra Vista

  35. Value of Telestroke: The Hub Hospital • Value to the neurologist • Role as regional stroke specialist • Satisfaction of being able to provide equal care • Greater comfort in treating patients remotely • Value to the hospital • Optimization of care • Provide care throughout a hospital system • Opportunity to extend technology to other services • Strengthen relationship with other hospitals

  36. Value of Telestroke: The Spoke Hospital • Value to treating physician • Improve care and outcomes for stroke patients through neurology support • Increase comfort level • Treating stroke • Administering tPA • Value to the hospital • Access to highly specialized neurological support • Improve patient outcomes • Capitalizes on any existing EMS diversion laws

  37. Elements Requiring Further Development and Refinement • Initial cost and ongoing maintenance of equipment and staff training • Comfort level with technology and reliability • Initial and ongoing training needs • Licensing and credentialing concerns • Reimbursement issues • Hub vs spoke • Consult compensation • Liability

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