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Saving Brain

By Lindsey Getz

Telemedicine can access care for stroke patients faster, but the technology costs remain a barrier to widespread adoption.

Using telemedicine to deliver stroke care can help save lives by providing 24-hour access to neurological experts, particularly in rural areas. But despite the known benefits of this technology, also called telestroke, cost continues to be at least one barrier preventing more widespread adoption. Still, there is optimism this barrier and others can be overcome.

In a recent study published online in Neurology, researchers found that using telestroke appears to be cost-effective for rural hospitals with no stroke experts on staff. While this offers hope, some physicians believe that without a closed-loop healthcare system, the cost savings won’t necessarily replace the technology’s output cost. 

The research involved data from previous telestroke studies as well as data from large multihospital telestroke network databases to calculate telestroke’s cost-effectiveness. It compared the costs and quality-adjusted life years of stroke patients treated by telestroke with those treated by usual care, such as a rural emergency department with neither telestroke nor stroke experts available.

A quality-adjusted life year is a measure of disease burden based on the number of years of life that would be added by using telestroke and the quality of life during those years. The study found that the cost of telestroke over a person’s lifetime was less than $2,500 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.

“We found telestroke to be extraordinarily cost-effective when measured by comparing quality-adjusted life years,” says lead author Jennifer J. Majersik, MD, MS, an assistant professor of neurology at the University of Utah School of Medicine in Salt Lake City. “So it seems like something we should invest in. In an era of spiraling healthcare costs, our findings give critical information to medical policy makers. 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.”

Time Is Brain
What makes a huge difference in the quality of life for patients treated with telestroke is the speed with which tissue plasminogen activator (tPA), the life-saving drug that dissolves clots and restores blood flow, can be administered. The faster it’s determined the patient is having a stroke and needs tPA, the less likely disability or death will result.

“As we follow patients forward—those who went to a hospital equipped with telestroke and those who did not—we found that only 2% to 4% of stroke patients received tPA with the lowest percentage in rural areas largely because there aren’t enough stroke experts with experience using tPA,” says Majersik. “Telestroke has the potential to lower this barrier by providing long-distance consultation to rural areas.”

Research has shown that tPA should be given within the first 4.5 hours after symptoms begin so timely administration of the drug is critical once it’s determined to be needed. “Time is brain,” says Justin Sattin, MD, an assistant professor in the University of Wisconsin (UW) School of Medicine and Public Health department of neurology and medical director of the UW Health Comprehensive Stroke Program. “Telestroke is great for specific decision-making opportunities, such as whether to give tPA or not.”

While Sattin touts the many benefits of implementing telestroke, he believes that making an effective cost-benefit analysis is incredibly difficult. Consequently, cost remains a huge barrier to adoption. “The fact is that the people who incur the costs aren’t the same people who necessarily see the cost savings in the long run,” he says. “A local hospital would need to invest in this technology as well as the professional stroke care expert to be on call.

“Of course it’s great if the patient gets tPA and sees a better outcome, but if they didn’t and have a worse outcome, in a perverse way the hospital actually makes more money,” he adds. “Sicker people are hospitalized longer and run up a larger bill. I’m not saying I believe hospitals want their patients to be sicker. But I’m saying that there is an issue to ponder when a small rural hospital invests a lot of money into a technology that they won’t necessarily see cost savings on.”

Additional Barriers
Anand Viswanathan, MD, PhD, associate director of Partners TeleStroke Program at Massachusetts General Hospital in Boston, says even physician acceptance can be a barrier to telestroke adoption. “A physician from a rural hospital who has never been exposed to something like this might not think it’s feasible,” he says. “That’s where physician and staff education are important. After some general education, physician and staff acceptance is more likely.”

Since telestroke allows for long-distance communication, physician licensing across state boundaries is another issue to consider. “Our program is in three states so that means physicians not only need to be licensed in Massachusetts but also in New Hampshire and Maine,” Viswanathan explains. “That can be a long process. Eventually switching to a more centralized licensing program would obviously make things much easier.”

While many barriers stand in the way of speedy telestroke adoption, the technology’s benefits are certainly impressive. Besides providing expert consultation on administering tPA, in many cases telestroke has prevented patients from being unnecessarily transferred to another facility. “Determining who needs to be transferred and who doesn’t is a definite benefit,” says Majersik. “Patients prefer to stay in their own hospital, and community hospitals prefer to keep their own patients when they can.”

“In many cases patients have strokelike mimics that actually wind up being something other than a stroke,” Viswanathan says. “These can often be ruled out by video-based consultation rather than transferring the patient. There is definitely a cost savings there.”

Ultimately, Sattin hopes that increased understanding about telestroke may help drive some demand. “Patients, community, and physicians could certainly drive demand for telestroke,” he says. “If they learn more about it in magazines like Aging Well, they may start to ask why their community hospital doesn’t have it available. The high cost of the technology is definitely an issue, but telestroke is also something that can really differentiate a hospital from its competitors. And there’s no doubt that it’s something that has the potential to save lives.” 

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.