Telemedicine to treat stroke patients is cost-effective over the long run and its expanded use may help to even out the disparities in stroke care around the country, according to a new statistical evaluation of telestroke costs.
University of Utah researchers used a statistical model to determine whether two-way, audiovisual technology to link stroke specialists to emergency room physicians and patients at remote hospitals was cost-effective compared to the usual system of caring for patients. In the Sept. 14 online edition of Neurology, they reported that telestroke, which involves upfront equipment costs as well as costs related to training and staffing costs, was marginally cost-effective in the short term, but it paid off when a long-term view was taken.
Jennifer Majersik, MD, assistant professor of neurology at the University of Utah and lead investigator for the study, told Neurology Today that while there is evidence to suggest that telemedicine can improve care for patients who are not at a stroke center, it was not so clear whether the approach made sense from the standpoint of cost-effectiveness. She said she hoped that this study will help bolster the case for telestroke, especially in rural areas where hospitals often don't have a stroke expert available on the spot.
“In this health care environment where costs are spiraling out of control, it is important to see that your dollars are well spent,” she said.
To study the cost-effectiveness issue, the researchers drew on data from studies in the medical literature, as well as the experiences of telestroke networks centered at the University of Utah and Mayo Clinic Hospital in Phoenix. They crunched the numbers for a theoretical network consisting of one “hub” hospital and eight “spokes.” Patients “entered” the model by presenting with acute ischemic stroke at one of the spoke hospitals. Costs and outcomes were compared between hospitals equipped with telestroke capacity and those that did not have it. Each patient in the model was assigned a severity score and a probability of receiving tissue plasminogen activator (tPA) and being transferred to a hub facility with stroke specialists. Costs that were taken into consideration in the model included hospital care, tPA, patient transfer between hub and stroke, and post-hospitalization caregiver costs. Outcomes were measured for both the 90-day period and the lifetime period using incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained.
Telestroke, compared to usual care, resulted, in an ICER of $108,363/QALY in the 90-day horizon and $2,229/QALY in the lifetime horizon. The approach becomes more cost-effective over time, Dr. Majersik said, because the major equipment costs are upfront.
The commonly accepted threshold for cost-effectiveness of an intervention has been $50,000 QALY, according to an editorial that accompanied the study, though that number may be outdated and upward of $100,000 or more could be considered acceptable.
INCREASED TPA USE
Lee H. Schwamm, MD, professor of neurology at Harvard Medical School, said the study on the cost-effectiveness of telestroke would be useful for policymakers who make decisions about insurance reimbursement. He said that physicians by and large agree on the value and cost-effectiveness of the approach, but insurance companies and legislative policymakers tend to have a different view.
“Currently, at least in the narrow interpretation of Medicare critical care billing requirements, face-to-face evaluation in the physical proximity of the patient is necessary,” Dr. Schwamm said. Most insurers don't pay at all, and for those who do, physicians end up having to bill a telestroke consultation as an outpatient visit, which pays significantly less than a critical care encounter.
Dr. Schwamm said there is plenty of evidence to show that making tPA more available would be a good thing for stroke patients.
“For every eight patients treated with tPA, one additional patient will have complete or near complete recovery, compared to usual care,” he said. “For every three patients you treat, one additional patient will have a major improvement.”
Telestroke is useful not only for allowing more stroke patients to be treated with tPA but in ruling out patients who are not candidates for the drug.
Dr. Majersik recalls one patient she evaluated remotely whose symptoms as told over the phone mimicked stroke, but after she evaluated the patient over the camera, she determined he was suffering from an Ambien overdose. He avoided being treated unnecessarily with tPA and being transferred to a tertiary hospital. But potential benefits of reduced costs in cases such as that were not modeled in this cost-effectiveness study.
Dr. Schwamm, who does research on telemedicine, said there is interest in expanding its use for other neurologic conditions, as well as expanding it into clinical practice and even into the homes of patients with chronic conditions.
Nelson RE, Saltzman GM, Majersik JJ, et al. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology 2011; E-pub 2011 Sept. 14.
Rudoph SH, Levine SR. Editorial: Telestroke, QALYs, and current health care policy: The Heisenberg uncertainty principle. Neurology 2011; E-pub 2011 Sept. 14.