Abstract
Introduction
This study evaluated the impact of establishing an inpatient teleneurology consultation service alongside an already established telestroke network on the stroke transfers to the hub. The study also aimed to assess the financial impact of establishing this network.
Methods
Prospectively collected data on all stroke patients evaluated through our telestroke and teleneurology networks between January 2008 and March 2018 were interrogated. For all spokes (eight sites) that had both teleneurology and telestroke services, we compared the rate of transfers to the hub before and after the establishment of the teleneurology network in August 2014. The cost reduction was estimated using the Medicare 5% standard analytic files.
Results
A total of 4296 stroke patients were evaluated during the study period. Of these, 2493 were seen before and 1803 were seen after the implementation of the teleneurology network at the included sites. Patients in the pre-teleneurology group were older (66.4 years (SD = 14.7 years) vs. 67.8 years (SD = 15.1 years); p = 0.002). Otherwise, there were no differences in baseline characteristics. Patients in the pre-teleneurology group were more likely to be transferred to the telestroke hub (29.4% vs. 20.2%; p < 0.001). The estimated mean cost reduction for each one minus the cost of transfer was estimated to be US$4997.
Discussion
The implementation of an inpatient teleneurology network was associated with a significant reduction in the transfer rate of stroke patients to hospitals with a higher level of care and could lead to a significant cost reduction.
Introduction
Stroke is a leading cause of death and disability worldwide. 1 Annually, there are 795,000 strokes in the USA, or one stroke every 40 seconds. 2 The term ‘time is brain’ was coined nearly a quarter of a century ago by Dr Camilo Gomez to acknowledge the impact of the passage of time on ischaemic brain tissue. 3 Unfortunately, while it is well recognised that time is of the essence when it comes to acute stroke treatment, inadequate access to stroke experts, particularly in rural areas, makes receiving optimal stroke care very challenging for patients living in such areas.4–6
The implementation and expansion of telestroke networks over the past few years has improved access to stroke experts for patients living in rural areas.7,8 Patients diagnosed with acute ischaemic stroke through telestroke consultation are typically evaluated for tissue plasminogen activator (tPA) treatment and are then either admitted locally or transferred to a primary or comprehensive stroke centre for further care. Following the groundbreaking mechanical thrombectomy trials in 2015, and more recently in 2018, which expanded the treatment window with mechanical thrombectomy to up to 24 hours from symptom onset, the number of thrombectomy patients is expected to increase significantly. Strategies aiming to identify patients who can remain at the community hospital have become necessary in order to enable thrombectomy-capable centres to continue to be able to provide care for patients who require a higher level of care. At the Medical University of South Carolina (MUSC), we have established a dedicated teleneurology network as a partner to our already established telestroke network to provide care to patients with non-acute strokes, post tPA and non-mechanical thrombectomy patients, as well as those with various other neurological conditions. 9
In this study, we evaluated the impact of establishing this teleneurology network on the rate of transfer of stroke patients to the hub and the cost reduction associated with establishing such a network.
Methods
Setting
The MUSC spoke-and-hub telestroke programme description and outcomes have been reported in detail previously.10–13 Patients who present to the emergency room at spoke sites with acute symptoms that are concerning for stroke are evaluated emergently through a telestroke consultation. Those patients who require thrombectomy candidacy evaluation or a higher level of care are identified and transferred immediately. Stroke patients who do not require transfer are usually admitted locally and are seen in follow-up with teleneurology consultation throughout the patient’s hospital stay. The MUSC teleneurology programme has been described previously. 9 Briefly, the programme was established in August 2014 to provide expert neurological consultation to patients presenting to community hospitals with various neurological conditions besides hyper-acute stroke which are routinely evaluated through the telestroke network. The decision regarding what type of consult is requested is at the discretion of the primary provider at spoke sites. In general, an acute telestroke consult is requested for patients presenting with stroke-like symptoms within 24 hours. The referring hospitals are able to choose the type of consult (acute stroke, acute teleneurology or routine neurology). However, they cannot choose whether the provider is a vascular or general neurologist. Our pool of telestroke providers includes 21 neurologists, of whom 16 are vascular neurologists and five are non-vascular neurologists.
Data collection
A retrospective review of the medical records of patients evaluated through the MUSC teleneurology and telestroke networks was performed. To evaluate the impact of the implementation of the teleneurology programme on transfer rate, we compared the rate of transfer of stroke patients to a tertiary medical centre before and after the implementation of the teleneurology consultation in partner sites using both teleneurology and telestroke consultation services. Collected data included age, sex, race, National Institutes of Health Stroke Scale (NIHSS) score on arrival, tPA administration and whether patients were seen in the referring hospital before or after establishing the teleneurology programme.
Cost analysis
To estimate the cost reduction of patient transfer to a tertiary medical centre for stroke care, we looked at the Medicare 5% standard analytic files. These files contain insurance reimbursement claims for a random 5% sample of Medicare beneficiaries in the state of South Carolina. Medicare beneficiaries include patients who are older than 65 years and patients with end-stage renal disease.
We screened the Medicare registry for patients with a discharge diagnosis of acute ischaemic stroke (ICD-10 codes used are in Supplemental Table 1e). We calculated the mean length of stay and mean daily charges for acute ischaemic stroke patients in the counties that contain the participating hospitals during the years 2014–2016. In addition, we calculated the mean cost of ambulance inter-hospital transfer from the included counties to the MUSC. Finally, we calculated the mean daily charges for acute ischaemic stroke patients at the MUSC.
Statistical analysis
Descriptive statistics were used to describe patient demographics and clinical outcomes. As appropriate, the t-test was used for normally distributed continuous variables, and the chi-square test was used for categorical variables. A binary logistic regression model was fit to investigate the association between the implementation of the teleneurology programme and the rate of transfer to a tertiary medical centre for stroke patients. Predictors considered for the evaluation included patient stroke severity (NIHSS), door-to-needle time, age, sex and race. An alpha level of 0.05 was used as the level of statistical significance. Data analysis was conducted using SPSS v25 software (IBM Corp., Armonk, NY).
Standard protocol approvals, registrations and patient consents
The study was approved by the Institutional Review Board (IRB) at the MUSC. The study was observational and carried minimal risk, and no subject consent was required per the MUSC IRB.
Results
Impact on the rate of transfer for stroke patients
At the included centres, a total of 4296 telestroke patients were evaluated for concern for acute ischaemic stroke between January 2008 and March 2018. Of those patients, 2493 acute stroke patients presented before the establishment of the teleneurology programme, and 1803 patients presented afterwards. The mean ages were 66.4 years (SD = 14.7 years) and 67.8 years (SD = 15.1 years) in each group, respectively (p = 0.002). No difference was found in sex distribution or mean admission NIHSS between both groups (Table 1). Patients who presented after the establishment of the teleneurology network were less likely to be transferred to the hub (transfer rate 20.2% after teleneurology vs. 29.4% before teleneurology; p < 0.001). Results of logistic regression show that the odds ratio for transfer to the hub was 0.573 (95% confidence interval 0.481–0.682) for patients who presented after implantation of the teleneurology programme, after controlling for baseline characteristics (age, sex, race, admission NIHSS and receiving tPA).
Baseline characteristics of telestroke patients who presented to hospitals that used both teleneurology and telestroke consultation services.
NIHSS: National Institutes of Health Stroke Scale.
Cost reduction from avoided transfers for stroke patients
Using the South Carolina Medicare 5% standard analytic files, the mean Medicare payment per hospital day for patients admitted with acute stroke is US$1401 (SD = US$770; range US$653–2694) for the eight hospitals that use both teleneurology and telestroke consultations. The mean payment for similar patients at the tertiary medical centre (MUSC) is $US2339 (SD = US$1811; range US$517–6410) per day. In addition, the mean ambulance fee for the stroke patients is US$307 (SD = US$27; range US$184.50–389.65). The mean length of stay for acute ischaemic stroke patients is five days. The total cost reduction (including transportation cost and higher cost at the tertiary medical centre) for each avoided transfer is about US$4997. If the rate of transfer to the tertiary medical centre for acute stroke care was similar before and after implementing teleneurology consultation, an additional 173 patients would have been transferred. So, the total cost reduction for the avoided transfers for stroke patients with the implementation of the teleneurology programme is about US$864,481.
Discussion
In this study, we report the impact of establishing a dedicated teleneurology network as a partner to a telestroke network on the transfer rate to the hub. We found that establishing a teleneurology network has led to a significant reduction in transfer rates, in addition to significant cost reduction.
Few previous studies have reported the benefits of teleneurology consultations. A study by Craig et al. in the UK that included 111 hospital patients showed that teleneurology consults could reduce the length of stay for patients with neurological complaints. 14 In a recent study, Shcreiber et al. reported that the application of a teleneurology network for veterans in a major metropolitan area successfully provided care for patients with a broad spectrum of neurological disorders. 15 Our study confirms these findings and provides important information about the impact of teleneurology networks on transfers to the higher-level hospital. In our study, we found that the odds of being transferred to a tertiary medical centre for acute stroke patients decreased by almost a half after the implementation of teleneurology consultations. This allows patients and families to stay closer to home and reserves beds at the tertiary medical centre for the sickest patients.
Furthermore, in this study, we found that the teleneurology programme has reduced the total cost of care on the health-care system for acute stroke patients. Our study estimates that the mean cost reduction from the reduced number of transfers is approximately US$5000 for each avoided stroke transfer. Several studies have evaluated the financial impact of various telemedicine networks. However, most of these studies largely evaluated the financial impact of establishing a telestroke network through which only patients with suspected acute ischaemic stroke were evaluated. Additionally, none of those studies evaluated the cost reduction resulting from avoiding transfers to the hub. A study by Switzer et al. evaluated the effect of a telestroke network in managing acute ischaemic stroke. They found that establishing a telestroke network improved the odds of receiving intravenous thrombolytics and therefore the odds of discharge home. 16 Another study reported that since the cost of telestroke is upfront but the benefits of improved stroke care are lifelong, telestroke networks are cost-effective in the long term. 17 Damaerschalk et al. found that telestroke patients incur costs of US$1436 per patient across their lifetime. 18 However, it is important to note that the cost-effectiveness of telestroke networks is less significant when accompanied by an increased spoke–hub transfer rate. 18 Our study is unique in that we evaluated the cost reduction of avoiding futile transfers to a centre that provided a higher level of care.
To the best of our knowledge, our study is the first to evaluate the impact of establishing a dedicated teleneurology network on the rate of transfer of stroke patients to a centre that provided a higher level of care. Our study is also the first to report on the financial impact of this network. Based on our study findings, we propose establishing a teleneurology network as a partner to telestroke. This teleneurology network aims at not only taking care of non-acute stroke patients but also providing follow-up for patients presenting with acute stroke but not requiring acute intervention, as well as patients presenting with various other less-acute neurological conditions.
Our study has a few limitations. The main limitation is driven by the retrospective nature of the study. Additionally, this is a single teleneurology network study, and our results might not be generalisable. Finally, while we were able to estimate the cost reduction, this is not a cost analysis study, and further costs should be taken into account such as the telemedicine consult fees.
In conclusion, the implementation of a dedicated teleneurology network can decrease the number of transfers of stroke patients to the hub and could be associated with significant cost reduction. Future prospective studies are required to confirm our findings.
Supplemental material
Supplemental material for Beyond acute stroke: Rate of stroke transfers to a tertiary centre following the implementation of a dedicated inpatient teleneurology network
Supplemental Material for Beyond acute stroke: Rate of stroke transfers to a tertiary centre following the implementation of a dedicated inpatient teleneurology network by Sami Al Kasab, Eyad Almallouhi, Ellen Debenham, Nancy Turner, Kit N Simpson and Christine A Holmstedt in Journal of Telemedicine and Telecare
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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