Telemedicine provides access to neurologists with expertise in stroke care. Photo source: www.billtruslow.com

Telestroke is a cost-effective strategy for treating ischemic stroke patients in rural hospitals that lack stroke expertise, according to a study published Sept. 14 in Neurology. While there are significant upfront costs in developing the two-way audiovisual technology, the lifetime savings of improved stroke care outweigh the initial costs, the study found.

“Healthcare has spiraling costs and one of the problems is we adopt new technologies because they are new without ascertaining if they benefit patients or are cheaper than other alternatives that might be just as effective,” the study's lead author Jennifer J. Majersik, MD, director the Stroke Center at the University of Utah Health Care in Salt Lake City, said in an interview.

The Joint Commission-accredited Primary Stroke Center is a hub for a telemedicine network that serves rural regions of Utah, Wyoming, Idaho and Nevada. “I am always aware of that, and wondered if we were being cost-effective in this case. I felt we were doing good, but I wasn’t sure,” she said.

Majersik and colleagues developed a model to assess the 90-day and lifetime benefits and costs of treating and managing patients with ischemic stroke using telestroke technology compared to usual care. In particular, they addressed the need to treat patients with IV tissue plasminogen activator (tPA) within a three to four-and-a-half hour time frame after symptom onset to effectively care for patients. Many rural areas, they note, lack stroke specialists with experience in using tPA.

“The vast majority of surveyed stroke specialists and emergency physicians think that telestroke can be effective at reducing geographical differences in stroke management and is superior to telephone consultation,” the authors wrote, “but they also cite implementation barriers of training time, cost of installation and reimbursement ambiguity.”

Majersik and colleagues built a decision analytic model with a hub hospital of stroke specialists that served community hospitals. The analysis calculated short-term (first 90 days after the incident stroke) and patient lifetime time frames. Outcomes included costs and quality-adjusted life years (QALYs).

Based on their model, the researchers found that in both time frames, costs were higher on average for telemedicine patients. They attributed that fact to the costs of the technology itself. They found that the incremental cost-effectiveness ratio (ICER) for telestroke in the 90-day time frame was $108,363/QALY. But under the lifetime time frame, the ICER was $2,449/QALY. They noted that $50,000/QALY is considered the threshold for cost-effectiveness, with more than $100,000/QALY deemed expensive.

Majersik said she expected the 90-day horizon to fall in the expensive region, based on initial investment costs for technology. “I knew it was expensive technology but that the benefits would last a lifetime,” she said. “We felt it was important to look at both the upfront costs and the long-term lifetime costs and outcomes.”

The authors wrote that telestroke removed a barrier in care for stroke patients in rural areas, and that lowering the cost of technology or increasing the reimbursement for telemedicine-provided care could further cost-effective benefits.

“[O]ur findings will give critical information to medical policymakers to help them determine if upfront investment in technology, infrastructure and human resources is worthwhile for the patients served by their health systems,” the authors wrote. “The cost-effectiveness of telestroke suggests that insurance plans should include urgent telestroke consultation as a covered benefit, particularly since lack of uniform reimbursement is a current barrier to adoption of the technology.”

In an accompanying editorial, Steven H. Rudolph, MD, and Steven R. Levine, MD, of the State University of New York Brooklyn Downstate Medical Center in Brooklyn, N.Y., agreed that telestroke offered benefits in the treatment of ischemic stroke. They pointed out that technology costs are dropping, and benefits such as educational gains and standardization extend beyond what was measurable in the study.

“As we focus on the fact that costs will need to be contained in our medical system, efforts will hopefully focus on the value, in addition to the costs, of healthcare intervention,” they wrote. “Telestroke appears to answer all of these questions positively, for the healthcare system, stroke neurologists and, most importantly, the patients.”