The State of Stroke In ArizonaThe State of Stroke In Arizona

Dr. Timothy IngallAssociate Professor of NeurologyCerebrovascular Diseases Center

Mayo Clinic Hospital

Stroke Programs in ArizonaStroke Programs in Arizona

Operation StrokeOperation Stroke

• A nationwide American Stroke Association initiative implemented in 1999.

• Two major goals: Reorganize stroke services to

provide better acute stroke care across the USA.

Implement OS in the largest 125 metropolitan areas by 2003.

Primary Stroke Center InitiativePrimary Stroke Center Initiative

• A collaborative effort between Operation Stroke and Arizona Emergency Medicine Systems (AEMS ) Regular meetings between

members of the OS Executive Committee and the AEMS Categorization Committee

Primary Stroke Center Initiative - Primary Stroke Center Initiative - TimelineTimeline

• 2001-2002 Stroke center surveys conducted

by both OS and AEMS based on modified PSC criteria

Help provided to hospitals that needed assistance to meet PSC criteria

Primary Stroke Center InitiativePrimary Stroke Center Initiative

• April 2003 Site visits commence for

hospitals requesting to be included in the AEMS PSC Matrix

Primary Stroke Center InitiativePrimary Stroke Center Initiative

September 2003 – proposal presented to AEMS Board to implement a limited PSC Matrix involving six hospitals.

Phoenix Primary Stroke Center InitiativePhoenix Primary Stroke Center InitiativeCurrently

Eight hospitals classified as Primary Stroke Centers based on the local certification process.

Phoenix Primary Stroke Center MatrixPhoenix Primary Stroke Center Matrix

Del WebbDel Webb

BoswellBoswell

Banner Banner ThunderbirdThunderbird

Banner Banner Good Good SamaritanSamaritan

Mayo Mayo HospitalHospital

BNI -- St. BNI -- St. Joseph’sJoseph’s

ArrowheadArrowhead

SMH SMH OsbornOsborn

Phoenix Stroke InitiativePhoenix Stroke Initiative - - ObjectivesObjectives1. Improve public awareness of stroke

symptoms and the need to call 911 if someone develops symptoms of a stroke.

2. Improve EMS delivery of acute stroke evaluation and transportation utilizing the Phoenix Primary Stroke Center matrix.

3. Increase the number of Joint Commission certified Primary Stroke Centers in Phoenix.

4. Increase the number of stroke survivors receiving stroke rehabilitation.

Arizona Cardiovascular Disease State PlanArizona Cardiovascular Disease State Plan

Cardiac disease and Stroke in AZCardiac disease and Stroke in AZ

• 240,000 Arizonans living with heart disease.

• 150,000 Arizonans living with stroke.

• Cardiac disease and stroke cost Arizona more than 2.5 billion dollars per year.

State Plan Vision and MissionState Plan Vision and Mission• Vision

• Reduce death and disability from Cardiovascular Disease in Arizona

• Mission• Reduce death and disability

associated with all cardiovascular diseases, particularly heart disease and stroke, using the most efficient, cost-effective and evidence-based strategies available.

Long Term ObjectivesLong Term Objectives

• Reduce the number of deaths related to heart disease by the year 2020

• Reduce the number of stroke deaths in Arizona by 20 percent by 2010.

• Increase the number of people who are aware of the signs and symptoms of a heart attack and a stroke and the importance of seeking immediate medical attention

Long Term ObjectivesLong Term Objectives

• Increase the number of Arizonans who have their high blood pressure under control by 25%.

• Increase the number of Arizonans who have their high cholesterol under control by 25%.

Long Term Objectives

• Promote cardiovascular health and prevent heart disease and stroke through interventions in multiple settings, for all age groups, and for the whole population, especially high risk populations.

2005-2008 AZ CV State Plan Activities2005-2008 AZ CV State Plan Activities

• Steering Committee Meeting created to establish priorities.

• Statewide CVD Coalition created.

CVD Coalition WorkgroupsCVD Coalition Workgroups

• Prevention• Emergency Response• Healthcare• Rehabilitation• Surveillance• Government Relations/Advocacy• Health Disparities

AZ CV Disease State PlanAZ CV Disease State PlanHealthcare PlanHealthcare Plan

• Establish a state wide network for providing care to acute stroke patients that matches the network of care developed for patients with acute cardiac problems

• Implement a telemedicine program – STARR (Stroke Telemedicine for Arizona Rural Residents)

Stroke TelemedicineStroke Telemedicine

•Frequent Use:Frequent Use:tele- medicine for stroketele- medicine for stroke11

tele- pathologytele- pathology tele- critical caretele- critical care tele- cardiologytele- cardiology22

tele- dermatologytele- dermatology tele- rheumatologytele- rheumatology tele- psychiatrytele- psychiatry tele- tele- surgerysurgery tele- neurosurgerytele- neurosurgery tele- traumatele- trauma33 tele- educationtele- education

tele- correctional caretele- correctional care

•Multiple Studies:Multiple Studies:***reliability******reliability*** well well established proof of conceptestablished proof of concept various systems/ various systems/ techniquestechniques

____________________________11Meyer et al. Neurology. 2005;64:1058-1060.Meyer et al. Neurology. 2005;64:1058-1060.

22Sable et al. Pediatrics. 2002; 109.Sable et al. Pediatrics. 2002; 109. 33Rogers et al. J. Trauma. 2001; 51: 1037-1041.Rogers et al. J. Trauma. 2001; 51: 1037-1041.

Telemedicine Studies:Telemedicine Studies:

- 1124 articles1124 articles- 50 reviewed 50 reviewed (assessment studies)(assessment studies)- 6 randomized controlled trials:6 randomized controlled trials:

- procedures sometimes not described- procedures sometimes not described- outcomes sometimes vague- outcomes sometimes vague- few economic analyses- few economic analyses- ? no clinical change or $ saved- ? no clinical change or $ saved

Results:Results:Evidence for effectiveness is lackingEvidence for effectiveness is lacking

Roine, Ohinmaa & Hailey, 2001:Roine, Ohinmaa & Hailey, 2001: Review Review

Telemedicine: BackgroundTelemedicine: Background

______________

Roine et al.. Canadian Medical Association Journal. 2001. 165:765-771.

◄

STRokE DOC: STRokE DOC: RCT RCT Telephone VS TelemedicineTelephone VS Telemedicine

*rt-PA = 24%

Trial Completed

Manuscript in press

Optimizing Stroke Care Through Telemedicine

Challenge: Stroke centers provide quality stroke care but have limited reach

Levine and McConnochie. Neurology. 2007;69:819-820. Meyer et al. Neurology. 2005;64:1058-1060. LaMonte et al. Stroke. 2003;34:725-728

Telemedicine• Well-established mechanism of providing specialized care beyond a hospital’s

physical confines• Uses technology to connect patient and physician with a remote specialist

• Telephone• Teleradiology• Videoconferencing

• The use of telemedicine for stroke care, termed “Telestroke”, now typically involves videoconferencing

Telestroke Facilitates Quality Care

• Increased rate of accurate assessment and appropriate treatment

• Ability to provide acute treatment to patients in remote areas

• Improved outcomes, reduced morbidity and mortality

• Increased comfort in the administration of tPA

• Greater opportunity for medical support and back-up

• Reduced incidence of protocol violations

• Equal access to acute stroke care in a variety of settings

Levine and McConnochie. Neurology. 2007;69:819-820. Meyer et al. Neurology. 2005;64:1058-1060. LaMonte et al. Stroke. 2003;34:725-728.

Potential benefits of telestroke

AHA/ASA Guidelines Support Implementation of Telestroke in Rural

Areas

Adams at al. Stroke. 2007;38(5):1655-1711

“Telemedicine can be an effective method to provide expert stroke care to patients located

in rural areas. Additional research and experience on the usefulness of telemedicine

are encouraged.”

Telestroke: Real-time Videoconferencing Enables Efficient Patient Assessment

• Visualization and interaction with patient for more accurate assessment

• Ability to obtain a valid NIHSS score

• Ability to view a CT scan in real time for reliable diagnosis

• Sharing patient records with remote physician

Vaishnav. Expert Rev Neurother. 2007;7:913-914. Shafqat. Stroke. 1999;30:2141-2145

Video expands and improves upon consultation by allowing…

Key Trends Driving Telestroke Implementation

Physicians• Increasing demand for stroke neurologists • Increasing involvement of ED physicians in stroke care

Hospitals• Increasing importance of quality initiatives• Increasing competition• Limited resources

Technology • Improving bandwidth/ communications• Wireless capabilities• Smaller devices/PDA

Community

TelestrokeTelestroke

• Increasing national and local recognition that stroke is under-treated

• Support for telemedicine networks through federal and state grants

Telestroke Systems Are Customizable

Configurations may include:• Desktop PC or laptop

• High speed internet access

• Camera on monitor directed at patient and remote physician

• IP/ISDN connection for videoconferencing

• Ability to view a CT scan in real time

• Data encryption supports HIPAA compliance

Vaishnav. Expert Rev Neurother. 2007;7:913-914. Shafqat. Stroke. 1999;30:2141-2145

Different Models of Telestroke

Spoke contracts with third party provider Neurologist employed by third party Spoke develops referral relationship with tertiary

hospital for more complex cases

Hub Hospital: designated stroke center

Spoke Hospitals: lack 24/7 neurology support

Hub

Neurologist

SpokeSpoke

Spoke

Spoke

Spoke

Spoke

Traditional “Hub and Spoke” Model

Third Party

Consult

Tertiary Hospital

Spoke

Neurologist Spoke

“Third Party Consult” Model

Increasing and Expanding Telestroke Networks in Urban and Rural Settings

Medical College of Georgia Remote Evaluation of Acute Ischemic Stroke

(REACH)

Michigan

Stroke Network

Mayo Clinic Mayo Clinic STARRSTARR

University of Texas

Health Sciences Center

The Maryland Brain Attack Center

Colorado Neurological

Stroke Center

University of Pittsburgh

Medical Center

University of California

Los Angeles

Partners TeleStroke Center

University of California San Diego

Utah Telehealth Network

Renown Institute for

Neuroscience

STRokE DOC Arizona Deployment Phase One

190 miles

184 miles

Mayo Clinic Hospital Stroke Center

STRokE DOC AZ TRIAL Stroke Team Remote Evaluation Using a Digital Observation Camera

The Initial Mayo Experience

Hotline activated on 68 occasions as of 7/31/0840 patients enrolled into study randomized to either telephone only or video/audio consult

35% of consults result in thrombolysis treatment

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DEC FEB APR JUNE AUG OCT DECTime

STRokE DOC Arizona TrialKRMC

YRMC

Cumulative Projected Randomized Patients(Approximately 4 per month)

STARR

Stroke Telemedicine for

Arizona Rural Residents

1. Kingman RMC

2. Yuma RMC

3. Chinle

4. Verde Valley

5. Northern AZ VA

6. La Paz

7. Cobre Valley

8. Carondalet

9. Sierra Vista

Value of Telestroke: The Hub Hospital • Value to the neurologist

•Role as regional stroke specialist•Satisfaction of being able to provide equal care•Greater comfort in treating patients remotely

• Value to the hospital • Optimization of care• Provide care throughout a hospital system• Opportunity to extend technology to other

services• Strengthen relationship with other hospitals

Value of Telestroke: The Spoke Hospital • Value to treating physician

•Improve care and outcomes for stroke patients through neurology support•Increase comfort level

•Treating stroke•Administering tPA

• Value to the hospital• Access to highly specialized neurological support• Improve patient outcomes• Capitalizes on any existing EMS diversion laws

Elements Requiring Further Development and Refinement

• Initial cost and ongoing maintenance of equipment and staff training

• Comfort level with technology and reliability• Initial and ongoing training needs• Licensing and credentialing concerns• Reimbursement issues

• Hub vs spoke• Consult compensation

• Liability