Economic Evaluation Protocol and Statistical Analysis Plan for the Cost-Effectiveness of a Novel Australian Stroke Telemedicine Program; the Victorian Stroke Telemedicine (VST) program

Economic and Performance Evaluation of E-Health before and after the Pandemic Era: A Literature Review and Future Perspectives

E-Health represents one of the pillars of the modern healthcare system and a strategy involving the use of digital and telemedicine tools to provide assistance to an increasing number of patients, reducing, at the same time, healthcare costs. Measuring and understanding the economic value and performance of e-Health tools is, therefore, essential to understanding the outcome and best uses of such technologies. The aim of this paper is to determine the most frequently used methods for measuring the economic value and the performance of services in the framework of e-Health, considering different pathologies. An in-depth analysis of 20 recent articles, rigorously selected from more than 5000 contributions, underlines a great interest from the clinical community in economic and performance-related topics. Several diseases are the object of detailed clinical trials and protocols, leading to various economic outcomes, especially in the COVID-19 post-pandemic era. Many e-Health tools are mentioned in the studies, especially those that appear more frequently in people's lives outside of the clinical setting, such as apps and web portals, which allow for clinicians to keep in contact with their patients. While such e-Health tools and programs are increasingly studied from practical perspectives, such as in the case of Virtual Hospital frameworks, there is a lack of consensus regarding the recommended models to map and report their economic outcomes and performance. More investigations and guidelines by scientific societies are advised to understand the potential and path of such an evolving and promising phenomenon.

Cost-effectiveness of the Victorian Stroke Telemedicine program

ObjectiveStroke telemedicine improves the provision of reperfusion therapies in regional hospitals, yet evidence of its cost-effectiveness using patient-level data is lacking. The aim of this study was to estimate the cost per quality-adjusted life year (QALY) gained from stroke telemedicine.MethodsAs part of the Victorian Stroke Telemedicine (VST) program, stroke telemedicine provided to 16 hospitals in regional Victoria was evaluated using a historical-control design. Patient-level costs from a societal perspective (2018 Australian dollars (A$)) and QALYs up to 12 months after stroke were estimated using data from medical records, surveys at 3 months and 12 months after stroke and multiple imputation. Multivariable regression models and bootstrapping were used to estimate differences between periods.ResultsCosts and health outcomes were estimated from 1024 confirmed strokes suffered by patients arriving at hospital within 4.5 h of stroke onset (median age 76 years, 55% male, 83% ischaemic stroke; 423 from the control period). Total costs to 12 months post stroke were estimated to be A$82 449 per person for the control period and A$82 259 in the intervention period (P = 0.986). QALYs at 12 months were estimated to be 0.43 per person for the control period and 0.5 per person in the intervention period (P = 0.02). Following 1000 iterations of bootstrapping, in comparison to the control period, the VST intervention was more effective and cost saving in 50.6% of iterations and cost-effective (A$0 and A$50 000 per QALY gained) in 10.4% of iterations.ConclusionThe VST program was likely to be cost saving or cost-effective. Our findings provide confidence in supporting wider implementation of telemedicine for acute stroke care in Australia.

Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark

Globally, there is a rise in incident cases of stroke, particularly in low- and middle-income countries, due to obesity-related and lifestyle risk factors, including health issues such as high cholesterol, diabetes and hypertension. Since the early 20th century, stroke mortality has declined due to proper management of the risk factors and improved treatment practices. However, despite the decline in mortality, there is an increase in the levels of disability that requires long-term support. In countries such as Australia and Denmark, where most care is provided within the community; family members, generally spouses, assume the role of caregiver, with little to no preparation that affects the quality of care provided to the person living with stroke. While past research has highlighted aspects to improve caregiver preparedness of stroke and its impact on care; health planning, recovery, and public health policies rarely consider these factors, reducing engagement and increasing uncertainty. Hence, there is a need to focus on improving strategies during recovery to promote caregiver engagement. In this study, we, therefore, try to understand the needs of the caregiver in stroke that limit engagement, and processes employed in countries such as Australia and Denmark to provide care for the person with stroke. Based on our understanding of these factors, we highlight the potential opportunities and challenges to promote caregiving engagement in these countries.

Ischemic Penumbra: A Personal View

The concept of the ischemic penumbra was defined over 40 years ago by Lindsay Symon and his group and is now an established principle of all acute ischemic stroke therapies. These reperfusion treatments rescue threatened, critically hypoperfused brain tissue and have been proven to improve clinical outcomes. We have been fortunate to have observed and played a small part in the penumbral story from its beginnings in the 1970s to its pivotal position today. Over this period, we have witnessed penumbral imaging evolve from positron emission tomography through to magnetic resonance imaging and now predominantly computed tomography perfusion, with the advent of automated imaging facilitating case selection for reperfusion therapies. We and others have conducted clinical trials using penumbral imaging to extend the time window for intravenous thrombolysis and select patients for thrombectomy. Together with the concept of fast- and slow-growing ischemic infarct patterns, this embeds the penumbral principle in everyday clinical management. The opportunity now exists to make penumbral imaging even more portable, affordable, and more widely available using mobile platforms, novel imaging techniques, digital linkage, and artificial intelligence.