- Email: [email protected]
Comparison of Stroke Outcomes of Hub and Spoke Hospital Treated Patients in Mayo Clinic Telestroke Program
Comparison of Stroke Outcomes of Hub and Spoke Hospital Treated Patients in Mayo Clinic Telestroke Program D1X XBart M. Demaerschalk, D2XMD, X *,†,‡,§ D3X XErica L. Boyd,D4X X║ D5X XKevin M. Barrett, D6XMD, X *,† D7X XDale M. Gamble,D8X X*,† D9X XSarah Sonchik,D10X X*,† D1X XMeghan M. Comer,D12X X*,† D13X XJudith Wieser,D14X X║ D15X XJoseph G. Hentz D16X XJ,║ D17X XDennis Fitz-Patrick,D18X X*,† and D19X XYu-Hui H. Chang,D20X X‡,║ Purpose: To examine telemedicine as it applies to acute ischemic stroke care at a spoke hospital and the effect on patient outcomes, including the timeliness of response, quality of care, safety, morbidity, and mortality when compared to standard hub hospital stroke center care. Methods: Retrospective review of prospectively entered quality/performance stroke/telestroke patient catalog data were completed for 1000 adult patients who presented with an acute ischemic stroke to the Mayo Clinic Hospitals (500 patients) or to one of thirteen Mayo Clinic affiliated telestroke spoke hospitals in the regions (500 patients). The primary outcome of interest was the percentage of accurate decision making for eligibility of IV alteplase administration assessed by blinded adjudication and the secondary outcomes pertained to complications, discharge parameters, and standard quality metrics. Results: There was no difference in the spoke hospital versus hub hospital groups in identifying and making the correct decision regarding which patients were eligible for IV alteplase administration (96% [95% confidence interval (CI): 94%-97%] versus 97% [95% CI: 95%-98%]; P = 0.32). There was no difference among the groups in proportion receiving IV alteplase, sustaining symptomatic intracranial hemorrhage, and mortality. Patients in the spoke group were less likely to have a favorable outcome at discharge, as defined by National Institutes of Health Stroke Scale (NIHSS): 0-1 or mRS: 0-1 or Glasgow Outcome Scale (GOS): 0-1 (21% versus, 35%; P < 0.001), were less likely to have venous thromboembolism prophylaxis (46% versus 63%; P < 0.01), were less likely to have received antithrombotic therapy (85% versus 90%; P = .02), were less likely to be discharged on anticoagulation when indicated (56% versus 64%; P = .01), and were less likely to be prescribed cholesterol reducing treatment (68% versus 72%; P < .001). The initial acute care hospital length of stay was longer for the spoke hospital group by one day (median: 4 versus 3; P < .001). Conclusion: The key findings were that evidencebased stroke thrombolysis eligibility decision making, thrombolysis administration, and thrombolysis emergency stroke metrics were uniformly excellent for the spoke hospital group when compared to the standard hub hospital group. However, evidence-based stroke hospitalization and discharge metrics were inferior for the spoke hospital group when compared to the standard hub hospital. Key Words: Telestroke—telemedicine—stroke—outcomes—emergency medicine. © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.
From the *Department of Neurology, Mayo Clinic, Phoenix, AZ; †Department of Neurology, Mayo Clinic, Jacksonville, FL; ‡Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN; §Center for Connected Care, Mayo Clinic, Rochester, MN; and ║Health Sciences Research, Mayo Clinic, Scottsdale, AZ. Received May 14, 2018; accepted June 17, 2018. Funding: Quality Improvement Project Grant from Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester MN. Disclosures: None. Address correspondence to Bart M. Demaerschalk, MD, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054. E-mail: [email protected] 1052-3057/$ - see front matter © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.06.024
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Journal of Stroke and Cerebrovascular Diseases, Vol. 27, No. 11 (November), 2018: pp 2940 2942
MAYO CLINIC TELESTROKE OUTCOMES
2941
Study Background and Purpose
in the outcomes between groups were tested by the Chi-square test (or Fisher's exact test) or Wilcoxon rank sum test. Statistical analysis was performed by the use of SAS 9.0 (SAS Institute, Cary, North Carolina).
Stroke is one of the most significant health problems in the United States and with an aging population it is projected to continue to increase significantly. To contain the devastating effects of stroke it is pertinent to have access to effective preventive therapy, early critical care, and rehabilitation. With this emphasis on effective treatment, telemedicine applied to stroke care has demonstrated the capability of extending the reach of stroke providers and improving the quality and timeliness of patient outcomes.1,2 Patients with acute ischemic stroke who present to community hospitals (nonstroke centers) ‘remote/ rural’ to the Mayo Clinic Hospitals and who are served ‘remotely/virtually’ via telemedicine by vascular neurologists on the Mayo Clinic stroke team comprise the ‘spoke’ hospital group. Patients with acute ischemic stroke at Mayo Clinic Hospitals (stroke centers) who are served directly by vascular neurologists on the Mayo Clinic stroke team comprise the standard ‘hub’ hospital group. Our study aims to examine telemedicine as it applies to acute ischemic stroke care at a spoke hospital and the effect on patient outcomes, including the timeliness of response, quality of care, safety, morbidity, and mortality when compared to standard hub hospital stroke center care. Mayo Clinic Institutional Review Board exempted this quality improvement study from full review.
Methods A retrospective electronic and paper record review of prospectively entered quality/performance stroke/telestroke patient catalog data were completed for 1000 adult patients (age 18) who presented with an acute ischemic stroke to the Mayo Clinic Hospitals in Phoenix, Arizona or Jacksonville, Florida (500 patients) or to one of thirteen Mayo Clinic affiliated telestroke spoke hospitals in the regions (500 patients). The primary outcome of interest was the percentage of accurate decision making for eligibility of IV alteplase administration, and this was assessed by blinded adjudication using the IV alteplase inclusion/ exclusion criteria by American Stroke Association/American Heart Association applicable at the time of the study.3 We evaluated whether differences existed in the primary outcome and the secondary outcomes (the administration of IV alteplase, complications, discharge outcomes, and the timeliness of the stroke team responses), whether direct in-person or virtual telemedicine between the spoke hospital group and the standard hub hospital group.
Statistical Methods Patient characteristics and outcomes by study groups (spoke versus hub) were described by percentages for categorical variables and median for continuous variables. The 95% confidence interval (CI) around the point estimate of the primary outcome was reported. The differences
Results A total of 1000 patients were identified between 2010 and 2014 for hub and spoke hospital groups. Patient median age was 74 (Interquartile range: 64-82) years and 57% were male. Patients in the spoke hospital group were younger (median 72 versus 77; P < .001). There were no differences in the baseline NIHSS scores and occurrence of prior stroke between study groups. There was no difference in the spoke hospital versus hub hospital groups in identifying and making the correct decision regarding which patients were eligible for IV alteplase administration (96% [95% CI: 94%-97%] versus 97% [95% CI: 95%98%]; P = .32). For those patients who received IV alteplase, the median time from stroke alert activation to start of treatment was 62 minutes (spoke) versus 71 minutes (hub) (P = .03). The results for the secondary outcomes were given in Table 1. There was no difference among the groups in complication of symptomatic intracranial hemorrhage, administration of IV alteplase, and mortality. Patients in the spoke group were less likely to have a favorable outcome, as defined by NIHSS:0-1 or mRS:0-1 or GOS:0-1 (21% versus, 35%; P < .001), were less likely to have venous thromboembolism prophylaxis (46% versus 63%; P < .01), were less likely to have received antithrombotic therapy (85% versus 90%; P = .02), were less likely to be discharged on anticoagulation (56% versus 64%; P = .01), and were less likely to be prescribed cholesterol reducing treatment (68% versus 72%; P < .001). The initial acute care hospital length of stay was longer for the spoke hospital group by one day (median: 4 versus 3; P < .001). The timeliness from symptom onset to emergency medical services, to emergency department, and to stroke team response was evaluated (Fig. 1). Compared to the hub hospital group, the patients in the spoke hospital group had a longer time to stroke alert activation (135 versus 89.5 minutes, P < .001), had a longer time to stroke team examination (148 versus 99 minutes, P < .001), and had a longer time to treatment (159 versus 129.5 minutes, P value < .001).
Discussion The key findings are that evidence-based stroke thrombolysis eligibility decision making, thrombolysis administration, and thrombolysis emergency stroke metrics were uniformly excellent for the spoke hospital group when compared to the standard hub hospital group. However, evidence-based stroke hospitalization and discharge metrics, for example length of stay, favorable outcome, venous thromboembolism prophylaxis, antithrombotic, anticoagulant, cholesterol lowering medication
B.M. DEMAERSCHALK ET AL.
2942
Table 1. Table of results Spoke (N = 500) n (%) Primary outcome IV alteplase eligibility correct decision making Secondary outcomes IV alteplase administered Post thrombolysis symptomatic ICH Favorable outcome (NIHSS:0-1 or mRS:0-1 or GOS:0-1) Death VTE prophylaxis Antithrombotic therapy administered by the end of hospital day 2 Discharged on anticoagulation Discharged on cholesterol reducing treatment Assessed for or received rehabilitation services during hospitalization Length of stay for initial acute care hospitalization (days), median Interquartile Range (IQR) Time from stroke alert activation to start of treatment (minutes), median (IQR)
Hub (N = 500) n (%)
Total (N = 1000) n (%)
478 (95.6%) 484 (96.8%) 962 (96.2%) 200 (40.1%) 13 (6.5%) 104 (20.8%) 26 (5.4%) 215 (45.8%) 338 (84.5%) 78 (56.1%) 299 (68.3%) 364 (86.3%) 4 (3-6)
P value
.32
180 (36.0%) 5 (2.8%) 173 (34.6%) 19 (3.8%) 312 (63.4%) 422 (89.6%) 128 (64.3%) 348 (71.8%) 445 (92.5%) 3 (2-5)
380 (38.0%) 18 (4.7%) 277 (27.7%) 45 (4.6%) 527 (54.8%) 760 (87.3%) 206 (60.9%) 647 (70.1%) 809 (89.6%) 3 (2-6)
.18 .09 <.001 .25 <.001 .02 .01 <.001 .002 <.001
62 (21-173) 70.5 (59-80)
66 (54-81)
.03
that have been shown to improve poststroke morbidity and mortality. These results should be added to the results of similarly designed studies.4 Future studies are required to examine optimal postemergency stroke telemedicine consultation delivery and reimbursement models.
References
Figure 1. Stroke alert time line.
administration (when indicated), and rehabilitation assessment were inferior for the spoke hospital group when compared to the standard hub hospital. This healthcare delivery study highlights the potential importance of developing and maintaining a continued stroke team presence, from emergency department arrival through to hospital discharge. The key recommendations include consideration of implementing an in-hospital stroke patient follow up predischarge telemedicine consult to ensure that patients at telemedicine spoke hospital sites have met important predischarge quality metrics
1. Demaerschalk BM, Berg J, Chong BW, et al. American telemedicine association: telestroke guidelines. Telemed J E Health 2017;23:376-389. https://doi.org/ 10.1089/tmj.2017.0006. Epub 2017 Apr 6. 2. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. American Heart Association Stroke Council; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2017;48:e3-e25. https://doi.org/10.1161/STR.0000000000000114. Epub 2016 Nov 3. Review. 3. Jauch EC, Saver JL, Adams Jr HP, et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870947. https://doi.org/10.1161/STR.0b013e318284056a. Epub 2013 Jan 31. 4. Heffner DL, Thirumala PD, Pokharna P, et al. Outcomes of spoke-retained telestroke patients versus hub-treated patients after intravenous thrombolysis: telestroke patient outcomes after thrombolysis. [Erratum appears in Stroke. 2016 Jan;47(1):e19; PMID: 26712954]. Stroke 2015;46:31613167.
From the *Department of Neurology, Mayo Clinic, Phoenix, AZ; †Department of Neurology, Mayo Clinic, Jacksonville, FL; ‡Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN; §Center for Connected Care, Mayo Clinic, Rochester, MN; and ║Health Sciences Research, Mayo Clinic, Scottsdale, AZ. Received May 14, 2018; accepted June 17, 2018. Funding: Quality Improvement Project Grant from Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester MN. Disclosures: None. Address correspondence to Bart M. Demaerschalk, MD, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054. E-mail: [email protected] 1052-3057/$ - see front matter © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.06.024
2940
Journal of Stroke and Cerebrovascular Diseases, Vol. 27, No. 11 (November), 2018: pp 2940 2942
MAYO CLINIC TELESTROKE OUTCOMES
2941
Study Background and Purpose
in the outcomes between groups were tested by the Chi-square test (or Fisher's exact test) or Wilcoxon rank sum test. Statistical analysis was performed by the use of SAS 9.0 (SAS Institute, Cary, North Carolina).
Stroke is one of the most significant health problems in the United States and with an aging population it is projected to continue to increase significantly. To contain the devastating effects of stroke it is pertinent to have access to effective preventive therapy, early critical care, and rehabilitation. With this emphasis on effective treatment, telemedicine applied to stroke care has demonstrated the capability of extending the reach of stroke providers and improving the quality and timeliness of patient outcomes.1,2 Patients with acute ischemic stroke who present to community hospitals (nonstroke centers) ‘remote/ rural’ to the Mayo Clinic Hospitals and who are served ‘remotely/virtually’ via telemedicine by vascular neurologists on the Mayo Clinic stroke team comprise the ‘spoke’ hospital group. Patients with acute ischemic stroke at Mayo Clinic Hospitals (stroke centers) who are served directly by vascular neurologists on the Mayo Clinic stroke team comprise the standard ‘hub’ hospital group. Our study aims to examine telemedicine as it applies to acute ischemic stroke care at a spoke hospital and the effect on patient outcomes, including the timeliness of response, quality of care, safety, morbidity, and mortality when compared to standard hub hospital stroke center care. Mayo Clinic Institutional Review Board exempted this quality improvement study from full review.
Methods A retrospective electronic and paper record review of prospectively entered quality/performance stroke/telestroke patient catalog data were completed for 1000 adult patients (age 18) who presented with an acute ischemic stroke to the Mayo Clinic Hospitals in Phoenix, Arizona or Jacksonville, Florida (500 patients) or to one of thirteen Mayo Clinic affiliated telestroke spoke hospitals in the regions (500 patients). The primary outcome of interest was the percentage of accurate decision making for eligibility of IV alteplase administration, and this was assessed by blinded adjudication using the IV alteplase inclusion/ exclusion criteria by American Stroke Association/American Heart Association applicable at the time of the study.3 We evaluated whether differences existed in the primary outcome and the secondary outcomes (the administration of IV alteplase, complications, discharge outcomes, and the timeliness of the stroke team responses), whether direct in-person or virtual telemedicine between the spoke hospital group and the standard hub hospital group.
Statistical Methods Patient characteristics and outcomes by study groups (spoke versus hub) were described by percentages for categorical variables and median for continuous variables. The 95% confidence interval (CI) around the point estimate of the primary outcome was reported. The differences
Results A total of 1000 patients were identified between 2010 and 2014 for hub and spoke hospital groups. Patient median age was 74 (Interquartile range: 64-82) years and 57% were male. Patients in the spoke hospital group were younger (median 72 versus 77; P < .001). There were no differences in the baseline NIHSS scores and occurrence of prior stroke between study groups. There was no difference in the spoke hospital versus hub hospital groups in identifying and making the correct decision regarding which patients were eligible for IV alteplase administration (96% [95% CI: 94%-97%] versus 97% [95% CI: 95%98%]; P = .32). For those patients who received IV alteplase, the median time from stroke alert activation to start of treatment was 62 minutes (spoke) versus 71 minutes (hub) (P = .03). The results for the secondary outcomes were given in Table 1. There was no difference among the groups in complication of symptomatic intracranial hemorrhage, administration of IV alteplase, and mortality. Patients in the spoke group were less likely to have a favorable outcome, as defined by NIHSS:0-1 or mRS:0-1 or GOS:0-1 (21% versus, 35%; P < .001), were less likely to have venous thromboembolism prophylaxis (46% versus 63%; P < .01), were less likely to have received antithrombotic therapy (85% versus 90%; P = .02), were less likely to be discharged on anticoagulation (56% versus 64%; P = .01), and were less likely to be prescribed cholesterol reducing treatment (68% versus 72%; P < .001). The initial acute care hospital length of stay was longer for the spoke hospital group by one day (median: 4 versus 3; P < .001). The timeliness from symptom onset to emergency medical services, to emergency department, and to stroke team response was evaluated (Fig. 1). Compared to the hub hospital group, the patients in the spoke hospital group had a longer time to stroke alert activation (135 versus 89.5 minutes, P < .001), had a longer time to stroke team examination (148 versus 99 minutes, P < .001), and had a longer time to treatment (159 versus 129.5 minutes, P value < .001).
Discussion The key findings are that evidence-based stroke thrombolysis eligibility decision making, thrombolysis administration, and thrombolysis emergency stroke metrics were uniformly excellent for the spoke hospital group when compared to the standard hub hospital group. However, evidence-based stroke hospitalization and discharge metrics, for example length of stay, favorable outcome, venous thromboembolism prophylaxis, antithrombotic, anticoagulant, cholesterol lowering medication
B.M. DEMAERSCHALK ET AL.
2942
Table 1. Table of results Spoke (N = 500) n (%) Primary outcome IV alteplase eligibility correct decision making Secondary outcomes IV alteplase administered Post thrombolysis symptomatic ICH Favorable outcome (NIHSS:0-1 or mRS:0-1 or GOS:0-1) Death VTE prophylaxis Antithrombotic therapy administered by the end of hospital day 2 Discharged on anticoagulation Discharged on cholesterol reducing treatment Assessed for or received rehabilitation services during hospitalization Length of stay for initial acute care hospitalization (days), median Interquartile Range (IQR) Time from stroke alert activation to start of treatment (minutes), median (IQR)
Hub (N = 500) n (%)
Total (N = 1000) n (%)
478 (95.6%) 484 (96.8%) 962 (96.2%) 200 (40.1%) 13 (6.5%) 104 (20.8%) 26 (5.4%) 215 (45.8%) 338 (84.5%) 78 (56.1%) 299 (68.3%) 364 (86.3%) 4 (3-6)
P value
.32
180 (36.0%) 5 (2.8%) 173 (34.6%) 19 (3.8%) 312 (63.4%) 422 (89.6%) 128 (64.3%) 348 (71.8%) 445 (92.5%) 3 (2-5)
380 (38.0%) 18 (4.7%) 277 (27.7%) 45 (4.6%) 527 (54.8%) 760 (87.3%) 206 (60.9%) 647 (70.1%) 809 (89.6%) 3 (2-6)
.18 .09 <.001 .25 <.001 .02 .01 <.001 .002 <.001
62 (21-173) 70.5 (59-80)
66 (54-81)
.03
that have been shown to improve poststroke morbidity and mortality. These results should be added to the results of similarly designed studies.4 Future studies are required to examine optimal postemergency stroke telemedicine consultation delivery and reimbursement models.
References
Figure 1. Stroke alert time line.
administration (when indicated), and rehabilitation assessment were inferior for the spoke hospital group when compared to the standard hub hospital. This healthcare delivery study highlights the potential importance of developing and maintaining a continued stroke team presence, from emergency department arrival through to hospital discharge. The key recommendations include consideration of implementing an in-hospital stroke patient follow up predischarge telemedicine consult to ensure that patients at telemedicine spoke hospital sites have met important predischarge quality metrics
1. Demaerschalk BM, Berg J, Chong BW, et al. American telemedicine association: telestroke guidelines. Telemed J E Health 2017;23:376-389. https://doi.org/ 10.1089/tmj.2017.0006. Epub 2017 Apr 6. 2. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. American Heart Association Stroke Council; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2017;48:e3-e25. https://doi.org/10.1161/STR.0000000000000114. Epub 2016 Nov 3. Review. 3. Jauch EC, Saver JL, Adams Jr HP, et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870947. https://doi.org/10.1161/STR.0b013e318284056a. Epub 2013 Jan 31. 4. Heffner DL, Thirumala PD, Pokharna P, et al. Outcomes of spoke-retained telestroke patients versus hub-treated patients after intravenous thrombolysis: telestroke patient outcomes after thrombolysis. [Erratum appears in Stroke. 2016 Jan;47(1):e19; PMID: 26712954]. Stroke 2015;46:31613167.