The World is “Flat”: A Brief Future of Acute Stroke Care

David C. Hess M.D.Professor and Chairman

Co-Director, Brain and Behavior Discovery InstituteDepartment of Neurology

Medical College of Georgia

Disclosures

Genentech Speaker’s Bureau

Boehringer Ingelheim Speaker’s Bureau

Co-Founder REACH CALL, Inc, Board of Directors

The Geographic Penalty The quality of stroke care is dependent upon

the hospital you go to

If you live in a rural area or “underserved acute stroke care” area you will NEVER receive tPA

There is a GEOGRAPHIC penalty for stroke care

Rural Hospitals are Plentiful

5759 Hospitals in the United States 4919 Community Hospitals 2003 Rural Hospitals (AHA Hospital Statistics

2006) 1464 Community Hospitals in a network 2669 Hospitals in a system

The Limited Resource: the Willing Neurologist

40% of Emergency physicians reluctant to use tPA (want a Neurologist)

In 2006-7 only 32 Fellows in approved Vascular Neurology Fellowships in U.S

By comparison, during same period, 2300 Fellows in Cardiology Fellowships in U.S.

Many Neurologists abandoning Emergency Department call

Limited resources for tPA:Supply and Demand

Limited supply of “willing” Neurologists

Geographically clustered at urban academic medical centers

50% of US Hospitals <100 beds

High ED Staff turnover

IT infrastructure limited

Rural, “frontier” locations

Stroke System Models1. The COMMANDO model: stroke specialist drives to

urban/suburban hospitals

2. Telephone “drip and ship”

3. Helicopter “ship and drip”

4. Telestroke

5. Telestroke with helicopter

U.S. Stroke Belt

Source: US Census Bureau Postcensal Population Estimates (IDC9 430-438.9) (1991-1995)

Hess DC et al. Lancet Neurol. 2006;36:5:275-8

REACH Hub & Spoke Telestroke Model

Components of Decision making

Reliability of NIH Stroke Scale Scores Review of images (CT head) History-taking (time of onset) Lab results, BP “Eye in the ED”

Feasibility and Reliability of NIHSS via Telestroke

Shafqat S(Stroke,1999)

Wang S(Stroke, 2003)

Handschu R(Stroke, 2003)

Meyer BC(Neurology, 2005)

System Point-to-point ISDN lines

Web-based,Mobile consultant

Point-to-point* Web-based,Mobile consultant

Number of patients

20 20 41 (ED) 25

Reliability Kappa r=.97

Pearsonr=.95

Kappa r=.85 to .99

Kappa r=.94

Time 9.70 min vs 6.55 min

9.11 min vs 6.24 min

11.4 min vs 10.8 min

NR

Comments Remote vs on site NIH all <3

Remote vs on site NIH all <3

Facial paresisleast reliable

Modified NIHSS also reliable

Prospective, Randomized Trial of Telemedicine vs Telephone

(Meyer BC et al, Lancet Neurol 2008)

Acute Stroke Patients(4 Community Hospital

Emergency Rooms)

Telemedicine 28% (31/111) tPA

Correct Treatment Decision: 98%*

Telephone23% (25/111) tPA

Correct Treatment Decision: 82%

No difference in 90 day functional outcome

The Underserved Rural Sites

REACH Mobile Cart in ED

Remote evaluation cart is mobile and can be moved throughout Emergency Department

Remote Neurologist Consultant Laptop

Wang S, et al. Stroke. 2004;35:1763-8

Video and CT scan viewing on Consultant laptop

Wang S, et al. Stroke. 2004;35:1763-8

Georgia REACH Telestroke Network

Hospital Bed size

ED volumeVisits/yr

Jenkins 10 3,312

Morgan 20 4,888

McDuffie 47 11,255

Jefferson 65 6,252

Wills 50 6,134

Washington 56 8,777

Emanuel 72 10,104

Elbert 52 7,322

Cobb 71 12,500

Tift 191 28,000Hess DC, et al Stroke. 2005 ;36(9):2018-2

Rural Georgia REACH Network 152 patients treated with tPA

Mean age 66; 56% women; 40% African American

Mean NIHSS 13; median 11

Mean door to needle: 80 min

47% treated < 2 hrs; 16%< 90 min

sICH 3% (5/146) NINDS; 0% SITS MOST

System OTT <90 min(%)

< 2 hr(%)

REACH Telestroke(N=50)

128 24 50

MCG ED (n=26)

146 19 35

Published stroke systems

148 <5-10 28

Comparison of Onset to Treatment times (OTT) between systems

(Switzer et al J Emergency Medicine, 2008 )

IV tPA Plus

Bridging with IV tPA to IA tPA

Merci Device and other mechanical thrombolysis methods

Use of transcranial doppler to use ultrasound-enhanced thrombolysis

Telestroke

More than a “tPA treatment tool”

Only about 15-20% of consults at MCG result in a tPA treatment

Many other acute disorders are identified

ECASS III

Window extended safety to 4.5 hours

But TIME still CRITICAL!!!!

“Having more time does not mean we should take more time”

SITS MOST Study (Lancet 2007; 369:275)

European Union required a registry of tPA (Alteplase) treated patients

6483 patients from 285 European centers

ICH in 1.7% ; 7.3% vs 8.6% (randomized studies) using Cochrane definition

tPA can be given safety and effectively in MANY centers

NY State Rural Telestroke system enabled by REACH

Most urgent needs

Systems of stroke care organized by regional or state health departments

Every patient should have quality stroke care regardless of geography

This will best be achieved with telestroke systems

Georgia Coverdell-Murphy Bill Signed into law May 14, 2008

Establishes two tiers of stroke centers

Primary Stroke Centers (Joint Commission certified)

Remote Treatment Stroke Centers (new level of identification for hospitals utilizing stroke-specific telemedicine technology)

Statewide Telestroke system with MCG Campus Hubs

“Fixed” vs Web-based Telestroke Fixed uses dedicated

ISDN lines Consultant must

travel to dedicated sites

Tempis (Bavaria) Mass General, BST

Mobile uses the web (broadband access)

Consultant can be anywhere*

Fast access REACH, BF (USCD)

Telestroke Issues State licensure issues and credentialing

Reimbursement (NY State Medicaid solving problem in NY)

Medicolegal (advantages of recording, documentation)

Cost

Conclusions Telestroke can “flatten” stroke care and bring

a stroke specialist to ANY rural, community hospital

Web-based telestroke systems are “fast” with potentially very short onset to treatment times

Academic Medical Centers should become Hubs and support community hospitals as Spokes

Acknowledgements

MCG REACH TEAM