Telestroke Cost-Effective in Improving Rural Care

Allison Gandey

September 14, 2011

September 14, 2011 — Hospitals that do not have an around-the-clock neurologist or stroke expert on staff can benefit from using 2-way audio-video telemedicine, a new study shows.

This first-of-its-kind cost-effectiveness study could be policy-changing, investigators say. "In an era of spiraling healthcare costs, our findings give critical information to medical policy makers," senior author Jennifer Majersik, MD, from the University of Utah School of Medicine in Salt Lake City, said in a news release. "If barriers to using telestroke, such as low reimbursement rates and high equipment costs are improved, telestroke has the potential to greatly diminish the striking disparity in stroke care for rural America."

The study was published online September 14 in Neurology.

Quicker tPA

The American Heart Association and American Stroke Association advocate for tissue plasminogen activator (tPA) use in appropriate patients as the most beneficial treatment for acute ischemic stroke.

Dr. Majersik pointed out that only 2% to 4% of patients with stroke receive treatment within the first 3 to 4.5 hours of symptom onset. "The lowest percentage is in rural areas largely because there aren't enough stroke experts with experience using tPA."

Telestroke has the potential to lower this barrier by providing long-distance consultation to rural areas, she said, "increasing the expertise and quality of stroke care at rural hospitals."

Investigators used data from previous telestroke studies and numbers from large, multihospital telestroke network databases at the University of Utah Hospitals and Clinics in Salt Lake City and the Mayo Clinic in Phoenix. They calculated the cost-effectiveness of telestroke by comparing the costs and quality-adjusted life years of patients with stroke who were treated virtually by telemedicine to those treated by usual care at a rural emergency department without a stroke expert available.

The researchers found that the cost of telestroke over a person's lifetime was less than $2500 per quality-adjusted life year. The threshold of $50,000 per quality-adjusted life year is commonly cited as the cut-off for cost-effectiveness.

Investigators found the large up-front fixed costs of equipment, network size, and training were high at the beginning, but tended to even out over time.

Policy Changing

In an accompanying editorial, Steven Rudolph, MD, from the Jaffe Stroke Center and the Mount Sinai School of Medicine, New York City, and Steven Levine, MD, from the State University of New York in Brooklyn, said, "These results argue strongly for policy change."

The editorialists point out that using the virtual approach as live off-site care has now been shown to be cost-effective, encouraging reimbursement for these services to the same extent as live, on-site care.

Telestroke appears to answer all of these questions positively.

"As we face the fact that costs will need to be controlled in our medical system," the editorialists note, efforts will hopefully focus on the value, in addition to the costs, of healthcare interventions. Telestroke appears to answer all of these questions positively, for the healthcare system, stroke neurologists, and most importantly, our patients."

"In the future," Dr. Majersik added, "we hope to expand this work to evaluate how the volume of telestroke systems, number of patients treated, and methods and distance of transportation affect the incremental cost-effectiveness ratios."

This study was supported by the National Institutes of Health and the National Cancer Institute. Dr. Majersik has provided expert testimony in a medico-legal case. Dr. Rudolph serves on the speakers' bureau for Boehringer Ingelheim. Dr. Levine works as associate editor for MEDLINK, served previously on an acute stroke advisory board, receives publishing royalties for Transient Ischemic Attacks, receives research support from the National Institutes of Health, and has reviewed medico-legal cases concerning acute stroke.

Neurology. Published online September 14, 2011. Article abstract, Editorial full text

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