Improving Access to Stroke CareChristine Holmstedt, DO, FAHA

Medical Director of Clinical Stroke Services

Director MUSC Telestroke

Disclosures

Research support› Genentech PRISMS Study› Covidien, Stryker, Penumbra POSITIVE Study› AstraZeneca SOCRATES Study› University of Calgary ESCAPE Study

Consultant for Medscape Education

Consultant for CE Outcomes

Non-commercial medicolegal consultant

Objectives

• Review the growing burden of stroke

• Describe current stroke treatments and the role of rapid stroke treatment in improving outcomes

• Review and describe how telestroke IMPROVES PATIENT ACCESS TO EXPERT STROKE CARE IN SOUTH CAROLINA

Objective 1

• Review the growing burden of stroke

Globally

Global Stroke Mortality Rates

(Kim and Johnston. Circulation 2011, 124:314-323)

Global Trends In Stroke

• Stroke is a growing global epidemic 1 in 6 people worldwide will have a stroke in their

life time 15 million new strokes each year; 6 million will

die 30 million stroke survivors with disabilities Disproportionate burden in developing countries

Nationally

Prevalence rates

Rate per millionpopulation

1,250 + (1,481.)1,080 to 1,2501,030 to 1,080

960 to 1,030below 960 (856)

Stroke is BAD

1 Kochanek KD et al. National Vital Statistics Reports. 2011;60(3).2. Roger VL et al. Circulation. 2012;125(1):e2–220.

• Leading cause of serious long term disability in the U.S.• 5th leading cause of death – 1 American dies every 4 minutes1

• Costs $36.5 billion annually – lost productivity and treatment2

• 130,000 Deaths each year - 1 in every 19 deaths.1

• >795,000 people in the US have a stroke. 610,000 are first or new strokes. 1 in 4 are recurrent strokes.2

Locally

Prevalence rates

Rate per millionpopulation

1,250 + (1,481.)1,080 to 1,2501,030 to 1,080

960 to 1,030below 960 (856)

South Carolina is SpecialStroke in SC is REALLY BAD

• SC is located in the buckle of the stroke belt

• Highest and second highest stroke mortality rate in U.S. (1983-2005)3,4

• In 2006 SC dropped to having the 8th highest stroke mortality rate5

• Stroke is the third leading cause of death in South Carolina although it is the 5th leading cause in North America5

Objective 2

• Describe current stroke treatments and the role of rapid stroke treatment in improving outcomes

Acute Stroke Treatments

Interventions:› IV tPA (0-3 hours) Approved 1996› IV tPA (3-4.5 hours) Updated 2010

› Devices Cleared for clot removal 2004,2008,2012› Thrombectomy

2015

Why is rapid treatment important?

In one minute• 1.9 million neurons are lost• 14 billion synapses are lost• 12 kilometers of

myelinated fibers are lost

Saver, J. Time is Brain – Quantified. Stroke. 2006 Jan;37(1):263-6.

Time to treatment influences outcomes

Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–74

Odds of a good outcome as defined at 3 month follow up by Hacke, et al:• Rankin (0–1), • Barthel (95–100),• NIHSS (0–1)

Odds ratioOR=2.8 at 0-90 minutesOR =1.6 at 91-180 minutesOR = 1.4 at 181-270 minutes

Time to treatment influences outcomes

Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–74

NNT= 2 NNT= 4 NNT= 9NNT is number of patients needed to treat for one to have a significantly improved outcome.

Figure. Number of patients who benefit and are harmed per 100 patients treated in each time window.

Lansberg M et al. Stroke 2009;40:2079-2084

Copyright © American Heart Association, Inc. All rights reserved.

Score Description0 No symptoms1 No significant disability despite

symptoms; able to carry out all usual duties and activities

2 Slight disability; unable to carry out all previous activities, but able to look after own affairs

3 Moderate disability; requiring some help, but able to walk without assistance

4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance

5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention

6 Dead

Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–74Bonita R, Beaglehole R. “Modification of Rankin Scale: Recovery of motor function after stroke.” Stroke 1988 Dec;19(12):1497-1500

Impact of time to treatment on long term disability

“The faster we move, the more our patients move”

Impact of tPA treatment

• Studies have demonstrated that the use of tPA is cost effective

• In South Carolina, there has been a $3,545 cost savings per patient over a six year period

• Other potential positive impacts• Social• Emotional

Objective 3

• Review and describe how telestroke IMPROVES PATIENT ACCESS TO EXPERT STROKE CARE IN SOUTH CAROLINA

Hospital Capabilities in Stroke

(Higashida, Stroke 2013;44)

Considerations in designing a stroke system in SC

• Geography and lack of access to care

• Hospital capability variation

• Time is brain and treatments must be delivered rapidly

• Lack of physician experience and comfort managing acute stroke patients

Telestroke is GOOD

• Telestroke partnerships offer cost-savings and have been shown to be effective and safe in treating patients8,9

• Gives patients across the state access to expert stroke care in less than 10 minutes (TIME IS BRAIN)

• Increases treatment with tPA

• Evaluation for thrombectomy candidacy

• Tool for education and information exchange

• Offers support to nurses and physicians across the state to keep patients closer to home

• Enhances collaboration and collegiality among hospitals

• Improved overall resource utilization

Improved access to expert stroke care

• In SC, Telestroke consultations are provided by MUSC Health Greenville Health Systems Palmetto Health Commercial Tele Services

• Using Geographic Information Systems (GIS) we estimated the percent of South Carolinians who would have access to “expert stroke care” within 30 or 60 minutes drive times.

• Expert stroke care defined as • Certified Primary Stroke Center (PSC) • PSC via telemedicine

Drive TimesCalculated using Arc Map software and population estimates by zipcode10

We used US Census Bureau’s ACS general population 2015 estimates and identified the PSCs and telestroke partners in SC in 2015

Access to expert stroke care WITHOUT telestroke services

• 35% within a 30 minute drive and

• 56% within a 60 minute drive

Access to stroke care WITH telestroke services

• 72% within a 30 minute drive and

• 96% within a 60 minute drive

Improved access to expert stroke care for vulnerable populations

Decreasing Disparities in Access to Care

30 min Drive w/out Telestroke

30 min Drive with Telestroke

60 min Drive with Telestroke

Black 29% 70% (+41%) 95% (+74%)

White 37% 71% (+34%) 96% (+59%)

Rural 15% 45% (+30%) 92% (+77%)

Medicaid 33% 70% (+37%) 96% (+63%)

Overall 35% 72% (+37%) 96% (+61%)

Improved access to expert stroke care for vulnerable populations

Access to expert stroke care WITHOUT telestroke services

• 29% of Blacks (non-Hispanic) have access to expert stroke care within 30 mins

• 37% of Whites (non Hispanic) have access to expert stroke care within 30 mins

Access to expert stroke care WITH telestroke services

• 70% of Blacks (non-Hispanic) have access to expert stroke care within 30 mins

• 71% of Whites (non Hispanic) have access to expert stroke care within 30 mins

Increasing access to expert stroke care

• Without telestroke, only 56%of SC residents are within a 60 minute ride of expert stroke care

• % of SC residents within a 60 minute ride of expert stroke care WITH telemedicine• 2012 76%• 2015 96%

• These improvements are especially important for those who face disparities in care• Age• Race• Rural residency• Education level• Poverty • Medicaid

References

1 Kochanek KD, Xu JQ, Murphy SL, Miniño AM, Kung HC. Deaths: final data for 2009.[PDF-371K] Nat Vital Stat Rep. 2011;60(3)2 Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2012:e2–241.3Boan, AD, Feng, WW, Ovbiagele, B, Bachman, DL, Ellis, C, Adams, RJ, Kautz, SA, and Lackland, DT. . Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of the stroke belt. Stroke. 2014;45(7): 1932-8. 4Castilla-Guerra, L, and Mikdad, AH. Stroke Prevention in the stroke belt: is the adolescence period the clue? Neurology. 2013; 80(18): 1628-9. 5The Burden of Heart Disease. http://www.scdhec.gov/library/CR-004470.pdf accessed 2/9/15. 6Holmes, M, Davis, S, and Simpson, E. Alteplase for the treatment of acute ischemic stroke: A NICE single technology appraisal; an evidence review group perspective. Pharmacoeconomics. 2014; E pub. PMID: 2544495. 7Kazley AS, Simpson A, Adams RJ, Simpson KN, Jauch E. Optimizing the Economic Impact of rtPA Use in a Stroke Belt State: The Case of South Carolina. American Health & Drug Benefits, 2013; 6(4).8Bart M. Demaerschalk, MD, MSc; Jeffrey A. Switzer, DO; Jipan Xie, MD, PhD; Liangyi Fan, BA; Kathleen F. Villa, MS; and Eric Q. Wu, PhD. Cost Utility of Hub-and-Spoke Telestroke Networks From Societal Perspective. American Journal of Managed Care, December 2013.9Zhai Y-k, Zhu W-j, Hou H-l, Sun D-x, Zhao J (2015). Efficacy of telemedicine for thrombolytic therapy in acute ischemic stroke: a meta-analysis. Journal of Telemedicine and Telecare. 2015; 21(3).10Kazley AS, Wilkerson RC, Jauch E, Adams RJ. Access to Expert Stroke Care with Telemedicine: REACH MUSC. Frontiers in Neurology, 2012; 3(44).