Access to Expert Stroke Care with Telemedicine: REACH MUSC

Express improvement of acute stroke care accessibility in large regions using a centralized telestroke network

Introduction:

Acute ischemic stroke therapy has improved in recent decades, decreasing the rates of disability and death among stroke patients. Unfortunately, all health care systems have geographical disparities in infrastructure for stroke patients. A centralized telestroke network might be a low-cost strategy to reduce differences in terms of geographical barriers, equitable access, and quality monitoring across different hospitals.

Aims:

We aimed to quantify changes in stroke patients’ geographic access to specialized evaluation by neurologists and to intravenous acute stroke reperfusion treatments following the rapid implementation of a centralized telestroke network in the large region of Andalusia (8.5 million inhabitants).

Methods:

We conducted an observational study using spatial and analytical methods to examine how a centralized telestroke network influences the quality and accessibility of stroke care for a large region.

Results:

In the pre-implementation period, 5,005,477 (59.72% of the Andalusian population) had access to specialized stroke care in less than 30 min. After the 5-month process of implementing the telestroke network, 7,832,988 (93.5%) inhabitants had an access time of less than 30 min, bridging the gap in acute stroke care in rural hospitals.

Conclusions:

A centralized telestroke network may be an efficient tool to reduce the differences in stroke care access and quality monitoring across different hospitals, especially in large regions with low population density.

Provider Communication and Telepresence Enhance Veteran Satisfaction With Telestroke Consultations

BACKGROUND AND PURPOSE

Telestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke; however, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration.

METHODS

Patients who received a telestroke consultation were eligible for a phone interview 2 weeks later, including questions about technology quality, telepresence, and telestroke provider communication. Satisfaction scores ranged from 1 to 7 (higher=more satisfied) and for analyses were dichotomized as 6 to 7 indicating high satisfaction versus <6. Patient variables including stroke severity (measured by the National Institutes of Health Stroke Scale) were obtained from study records. Generalized estimating equation models were used to determine what factors were associated with patient satisfaction.

RESULTS

Over 18 months, 186 interviews were completed, and 142 (76%) reported high satisfaction with telestroke. Patients with more severe stroke were less likely to recall the consultation. Factors significantly associated with patient satisfaction were higher ratings of the technology (P<0.0001), telepresence (P<0.0001), provider communication ratings (P<0.0001), and overall Veterans Affairs satisfaction (P=0.02). In the multivariate model, telepresence (odds ratio, 3.10 [95% CI, 1.81-5.31]) and provider ratings (odds ratio, 2.37 [95% CI, 1.20-4.68]) were independently associated with satisfaction. Veterans who were satisfied were more likely to recommend the technology (P<0.0001).

CONCLUSIONS

Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with the telestroke consultation. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence could improve patient experience with telestroke consultation.

Population Health Indicators Associated with a Statewide Telestroke Program

Background: Studies show that telestroke (TS) improves rural access to care and outcome for stroke patients receiving TS services, but population health impacts of TS are not known. We examine impacts associated with South Carolina's (SC) statewide TS network on an entire state population of patients suffering acute ischemic stroke (AIS) as TS became available across SC counties. Methods: A population health study using Donabedian's conceptual model and an ecological design to describe the change observed over time in use of thrombolysis and endovascular therapy (EVT) as the SC TeleStroke Network (SCTN) diffused across SC counties. Changes in county rates of stroke mortality and discharge destination are reported. The unit of interest is the population rate for AIS patients living in a SC county. Patients' county of residence at the time of hospitalization defined county cohorts. Relative risks were estimated using logistic regression adjusted for age >75 years. Results: Overall tissue plasminogen activator (tPA) rate was 6.28%, and EVT rate was 1.10%. Patients living where SCTN was available had a 25% higher likelihood of receiving tPA (adjusted relative risk [ARR] = 1.25, 95% confidence interval [CI] = 1.15-1.36) and lower risks of mortality (ARR = 0.91; 95% CI = 0.84-0.99) or discharge to skilled nursing (ARR = 0.93; 95% CI = 0.89-0.97). Conclusions: TS diffusion affects the structure of the health system serving a county, as well as the processes of care delivered in the emergency department; these changes are associated with measurable population health improvements. Results support a population benefit of TS implementation.

"The Closer, the Better:" The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina

BACKGROUND

Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception.

OBJECTIVE

To understand women's contraceptive needs and perceptions of accessing contraception through telehealth services.

METHODS

Researchers conducted 52 in-depth interviews with women ages 18-44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2.

RESULTS

Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women's complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women's overall health and well-being.

CONCLUSIONS FOR PRACTICE

Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women's access to contraceptive methods in rural areas.

Implementation and Evaluation of an Economic Model for Telestroke: Experience from Virtuall, France

Background

Telestroke is recognized as a safe and time-efficient way of treating stroke patients. However, admission centers (spokes) are subject to financial charges which can make them reluctant to join the system. We implemented and assessed an economic model supporting our telestroke system, Virtuall, France, which includes one expert center (hub) and six spokes.

Methods

The model is based on payment for the expertise provided by the hub, distribution of charges related to telemedicine according to the fees perceived by the spokes, and transfer of patients between the spokes and the hub. We performed a cost–benefit analysis for all patients included in Virtuall from January 2014 to December 2015 to assess the economic balance in each center.

Results

321 patients were prospectively included in the study. Application of the economic model resulted in overall financial balance with funding of a dedicated medical service in the hub, and reduced costs directly related to telestroke by an average of 10% in the spokes. The conditions generating the highest costs for the spokes were: a patient returning from the hub for re-hospitalization (mean cost of $1,995/patient); management of patients treated by intravenous thrombolysis without transfer to the hub (mean cost of $2,075/patient). The most favorable financial condition for the spokes remained simple transfer of patients to the hub and no return (mean cost of $329/patient).

Conclusion

We describe an economic model which can be applied to any telestroke system to ensure the optimal balance between hub and spoke centers.

Telestroke-the promise and the challenge. Part one: growth and current practice

Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the first of a detailed two part review, and explores the growth and current practice of telestroke, including the specific role it plays in the assessment and management of patients after emergent large vessel occlusion.

The effects of telemedicine on racial and ethnic disparities in access to acute stroke care

Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine.

Telestroke in an urban setting

BACKGROUND

Telestroke is a viable alternative in rural areas where neurologists or stroke expertise is unavailable. Urban applications of telestroke have not been previously described.

MATERIALS AND METHODS

All patients evaluated using remote telestroke technology at four urban spoke hospitals between March 2011 and March 2013 were included in this analysis. Telestroke services were provided by vascular fellowship-trained neurologists at one academic stroke center. Patient characteristics, time to initiation of consult, and treatment decisions were prospectively recorded. Stroke triage protocols and thrombolysis rates prior to initiation of telestroke were also obtained.

RESULTS

Four hundred ninety-eight patients were evaluated during the study period; mean age was 64.5 years, and 60.4% were female. Median time from initial emergency room call to start of teleconsult was 5 (range, 1-51) minutes. Average length of teleconsult was 30 minutes. Technical difficulties occurred in 80 (16.0%) teleconsults, but only 1 was major. Daytime calls (8 a.m.-5 p.m. Monday-Friday) accounted for 38.2% of teleconsults. Two hundred eighty-one patients (56.4%) were determined by teleconsult to have an acute ischemic stroke or transient ischemic attack (TIA). In 72 patients (14.5% overall; 25.6% of all ischemic stroke/TIA patients), intravenous alteplase (tissue plasminogen activator) was recommended. Transfer to the hub hospital occurred in 75 patients (15.1%).

CONCLUSIONS

Telestroke is a rapid and effective way to assess patients with suspected acute stroke in an urban setting. Its use may increase access to stroke neurologists and improve thrombolysis rates where competing responsibilities may delay, prevent, and even dissuade on-site evaluation by neurologists.

Assimilation of web-based urgent stroke evaluation: a qualitative study of two networks

Background

Stroke is a leading cause of death and serious, long-term disability across the world. Urgent stroke care treatment is time-sensitive and requires a stroke-trained neurologist for clinical diagnosis. Rural areas, where neurologists and stroke specialists are lacking, have a high incidence of stroke-related death and disability. By virtually connecting emergency department physicians in rural hospitals to regional medical centers for consultations, specialized Web-based stroke evaluation systems (telestroke) have helped address the challenge of urgent stroke care in underserved communities. However, many rural hospitals that have deployed telestroke have not fully assimilated this technology.

Objective

The objective of this study was to explore potential sources of variations in the utilization of a Web-based telestroke system for urgent stroke evaluation and propose a telestroke assimilation model to improve stroke care performance.

Methods

An exploratory, qualitative case study of two telestroke networks, each comprising an academic stroke center (hub) and connected rural hospitals (spokes), was conducted. Data were collected from 50 semistructured interviews with 40 stakeholders, telestroke usage logs from 32 spokes, site visits, published papers, and reports.

Results

The two networks used identical technology (called Remote Evaluation of Acute isCHemic stroke, REACH) and were of similar size and complexity, but showed large variations in telestroke assimilation across spokes. Several observed hub- and spoke-related characteristics can explain these variations. The hub-related characteristics included telestroke institutionalization into stroke care, resources for the telestroke program, ongoing support for stroke readiness of spokes, telestroke performance monitoring, and continuous telestroke process improvement. The spoke-related characteristics included managerial telestroke championship, stroke center certification, dedicated telestroke coordinator, stroke committee of key stakeholders, local neurological expertise, and continuous telestroke process improvement.

Conclusions

Rural hospitals can improve their stroke readiness with use of telestroke systems. However, they need to integrate the technology into their stroke delivery processes. A telestroke assimilation model may improve stroke care performance.

Impact of Telemedicine on Access to Acute Stroke Care in the State of Texas

Background

To examine the impact of telemedicine (TM) on access to acute stroke care and expertise in the state of Texas.

Methods

Texas hospitals were surveyed using a standard questionnaire and categorized as: (1) stand-alone Primary Stroke Centers (PSC) not using TM for acute stroke care, (2) PSC using TM for acute stroke care, (3) non-PSC hospitals using TM for acute stroke care, or (4) non-PSC hospitals not using TM for acute stroke care. Population data were obtained from the U.S. Census Bureau and the Neilson Claritas Demographic Estimation Program. Access within 60 min to a designated facility was calculated at the block group level.

Results

Over 75% of Texans had 60-min access to a stand-alone PSC. Including PSC using TM increased access by 6.5%. Adding non-PSC that use TM for acute stroke care provided 60-min access for an additional 2% of Texans, leaving 16% of Texans without 60-min access to acute stroke care. Approximately 62% of Texans had 60-min access to more than one type of facility that provided acute stroke care.

Conclusion

The use of TM in the state of Texas brought 60-min access to >2 million Texans who otherwise would not have had access to acute stroke expertise. Our findings demonstrate that using TM for acute stroke has the ability to provide neurologically underserved areas access to acute stroke care.

Improving stroke outcomes in rural areas through telestroke programs: an examination of barriers, facilitators, and state policies

INTRODUCTION

Every year in the United States more than 600,000 ischemic stroke patients do not receive proven, effective stroke treatment or may not be medically eligible to receive the one medication endorsed by the U.S. Food and Drug Administration for acute ischemic stroke. The lack of treatment is due partly to shortages of neurological experts in rural and underserved areas. Telestroke programs can improve stroke care for stroke patients in rural and underserved settings by using interactive telecommunication technology that connects centrally located neurological experts to rural healthcare facilities. Many states have enacted policies and practices that facilitate telestroke access.

MATERIALS AND METHODS

We reviewed statutes and regulations in all 50 states that affect the adoption of telemedicine programs and describe examples of state-implemented programs in two states with policies that encourage telestroke use.

RESULTS AND DISCUSSION

This review presents evidence of the value and effectiveness of telestroke programs, as well as an explanation of common barriers and facilitators of telestroke, including licensing and credentialing rules, reimbursement issues, and liability concerns. Most states have adopted policies that affect the adoption of telestroke programs. Georgia and South Carolina are examples of states implementing stroke policies using a telestroke model to treat stroke patients in rural areas.

Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke

BACKGROUND AND PURPOSE

Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt).

METHODS

Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC.

RESULTS

Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78).

CONCLUSIONS

Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.

Telemedicine in stroke care and rehabilitation

Telemedicine allows prompt assessment of acute stroke patients. This new technology has increased the administration of intravenous recombinant tissue plasminogen activator (rtPA) to eligible patients. In addition, telemedicine is being utilized in the rehabilitation of patients with cerebrovascular disease. This article will review the use of telemedicine in patients with acute ischemic stroke and its implementation in telerehabilitation to patients with residual neurologic deficits.