Evaluation of the Impact of Telemedicine onAccess to Stroke Care in OregonEvaluation of the Impact of Telemedicine on Access to Stroke Care in OregonMcDaneld L1, Wolff CS2, Salhi R2, Tommasini A2, Branas CC2, Lutsep H1, Carr BG2.1. Dept. of Neurology, Oregon Health and Science University, Portland, OR2. Dept. of Epidemiology, University of Pennsylvania, Philadelphia, PA
Access to in-person Access to telemedical Access to both No access to Total responsesstroke care stroke care telemedical and in- telemedical or in- (response rate) person stroke care person stroke care43% 76% 40% 20% 51/57 (89%)
Introduction• Acute ischemic stroke is a leading cause of serious neurologic disability in the US• Tissue plasminogen activator (tPA) administered within 4.5 hours of onset is an effective treatment for acute ischemic stroke (1, 2) but tPA treatment rates are estimated to be only 3.5-8% (3)• Access to appropriate specialty care is limited; only 66% of the US population can reach a stroke center in 60 minutes or less (4), and 77% of US counties do not have a hospital with neurological services (5)• Telemedical consultation for stroke results in a high proportion of correct treatment decisions (6, 7) and could improve access to stroke care
Objective• To evaluate the impact of telemedical networks on access to stroke care within the state of Oregon, which has a small urbanized corridor and a large rural area.
MethodsData:• Hospital and Primary Stroke Center (PSC) Certification data were obtained from the Joint Commission.• 2010 Neilson Claritas Demographic data were used for block-group population data.• The 2009 Area Resource File was used to obtain county-level demographic data.• Hospital Identification and Classification:• All acute care hospitals in Oregon were identified using The Joint Commission data• Between 9/2011 – 2/2012 ED Directors, nurse managers, or stroke coordinators at all identified hospitals were contacted to complete a semi-structured phone survey, with follow-up calls if necessary• Survey focused on stroke capabilities including self-designation as a stroke center and availability of telemedical supportAccess Calculations:• Total time from population-weighted block group central point to nearest PSC was calculated using existing road networks and speeds and prehospital time estimates as has been described elsewhere (8).• Geographic access was calculated by summing the population within 60 minutes by ground from a primary stroke center, telemedicine site, or both.
Results• In-person stroke care was available in more densely populated areas as compared to areas with telemedicine access (858.9 pop/sq. mi vs. 184.8 pop/sq. mi, p < 0.05)• Compared to counties with low rates of telemedicine access, counties with high rates of telemedicine access had:• Lower uninsured rates (19.6% vs. 22.5%, p <0.05)• Smaller older adult populations (16.4% vs. 19.3% p <0.05)• No significant differences in poverty rates (15.4% vs. 15.0%, p=0.63), median household income ($42,146 vs. $44,200, p=0.37), or percent Hispanic (8.0% vs. 11.3% p=0.21)• No meaningful difference in percent black (0.4% vs. 0.7%, p < 0.05).
Limitations• We examined differences in access to care rather than differences in outcomes; the latter is likely a more accurate measure of population benefit.• Hospitals were identified via The Joint Commission’s database and thus hospitals that are not TJC certified were not included.• Prehospital time estimates were used as actual prehospital times are not available.
Discussion• Telemedicine has reduced the percent of the population without access to stroke care from 57% to 20%.• Of those with access to telemedical care, more than half also had in-person access to care.• High rates of telemedicine access was associated with lower uninsured rates and younger populations compared to areas with low rates of telemedicine access.• No meaningful racial discrepancies were noted.
References1. Tissue Plasminogen Activator for Acute Ischemic Stroke, rt-PA Study Group, NEJM 19952. Thrombolysis with Alteplace 3 to 4.5 hours after Acute Ischemic Stroke, Hacke et al, NEJM 20083. Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Reeves et al, Paul Coverdell Prototype Registries Writing Group, Stroke 20054. StrokeMaps.org 2010 Stroke Center Maps, Carr et al, University of Pennsylvania Cartographic Modeling Laboratory, Available from: www.strokemaps.org5. Heart Disease and Stroke Statistics – 2010 Update, Lloyd-Jones et al, Circulation 20096. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study, Meyer et al, Lancet Neurology 20087. Stroke Team Remote Evaluation Using a Digital Observation Camera in Arizona – The Initial Mayo Clinic Experience, Demaershalk et al, Stroke 20108. Access to trauma centers in the United States. Branas et al, JAMA 2005