Two million neurons die per every minute that a stroke goes untreated, making rapid diagnosis and treatment crucial for the best outcomes. However, 45 percent of Americans live more than 60 minutes away from a primary stroke center. Enter telemedicine: telestroke networks have sprung up across the U.S., and are rapidly expanding, delivering revenue gains and improving patient outcomes.
Two years into a five-year business plan, the Mayo Clinic telestroke network serves 10 hospitals in Arizona, one in Missouri, one in Florida and is in the process of being offered in Minnesota and surrounding states. It has also piloted international care in Canada, Mexico, Spain, India and Bhutan. "We've experienced tremendous growth," says Bart Demaerschalk, MD, director of the network based at the hub hospital of Mayo Clinic Hospital in Phoenix. The plan is designed to accommodate nearly 40 spoke hospitals in Arizona alone.
The hub-and-spoke model consists of one hub hospital—a primary stroke center—that provides stroke services to several smaller spoke hospitals. A hub-based stroke specialist observes the patient through a cart-mounted computer screen, or robot, and communicates with the patient and caregivers at the spoke site, similar to videoconferencing.
Because there are two kinds of stroke, ischemic and hemorrhagic, rapid imaging, diagnosis and evaluation is crucial to the best possible outcome. Treatments are very different so quick access to knowledgeable, experienced clinicians is vital. And, every delay in treatment requires more imaging to assess progress of the disease. In Demaerschalk's network, both the spoke hospital radiologist and the Mayo Clinic telestrokologist interpret the CT brain scan. For patients with a complex stroke, such as a ruptured intracranial aneurysm causing a subarachnoid hemorrhage, the Mayo Clinic telestrokologist is joined by the Mayo Clinic teleneuroradiologist, tele-endovascular surgical neuroradiologist and teleneurosurgeon to conduct a collaborative assessment, establish a diagnosis and embark on an emergency management plan.
Radiology and informatics infrastructure are just part of the equation for a stroke network. To successfully participate in a network, a spoke hospital needs clinical and administrative leadership that recognize a deficiency of clinical neurology expertise and is open to telemedicine.
"What we've done is taken a small critical access hospital in a very isolated area and given it a medical capacity it never had," says James Dickson, CEO of Copper Queen Community Hospital (CQCH), a 14-bed hospital and part of the Mayo Clinic Telestroke network. Since becoming a spoke hospital in 2009, CQCH has transferred 35 fewer patients and seen an increase in its patient census of 5 to 6 percent, which directly translates to increased revenue.
Dickson says the telestroke program requires a significant amount of preparation, including training and certifying nurses in stroke care, learning to use new pharmaceuticals—specifically Tissue Plasminogen Activator (tPA)—and expanding rehabilitation services. tPA, the only thrombolytic agent approved by the FDA for treating acute ischemic stroke, offers a 30 to 50 percent better chance of cure from stroke disability as long as treatment begins within a 4.5-hour window.
Network-wide, Mayo Clinic has reduced patient transfers from 90 percent to 30 percent, Demaerschalk says. By keeping most patients in community hospitals, those facilities experience revenue gains. The network also has increased the opportunities for treatment with tPA, which means an increase in reimbursement since Medicare pays a much higher rate for increased complexity—approximately $6,000 per case. Mayo's spoke hospitals increased tPA use from a baseline of 2 percent of stroke patients prior to the program to up to 25 percent after joining the network.
Another measured outcome is accuracy of diagnosis. After completing nearly 700 telestroke consultations, Demaerschalk found 96 percent accuracy in diagnosing stroke, compared with 83 percent accuracy for phone-only consultations.
Where's the money?
Despite these benefits, telestroke programs are hampered by the overhead. From 2007 to 2010, the Mayo Clinic Telestroke network was completely funded by the Arizona Department of Health Services. A $1.5 million state grant funded the design and implementation of a telestroke