The State of Stroke In Arizona

1
The State of Stroke In Arizona

• Dr. Timothy Ingall
• Associate Professor of Neurology
• Cerebrovascular Diseases Center
• Mayo Clinic Hospital

2
Stroke Programs in Arizona
3
Operation 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.

4
Primary 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

5
Primary Stroke Center Initiative - Timeline

• 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

6
Primary Stroke Center Initiative

• April 2003
• Site visits commence for hospitals requesting to
  be included in the AEMS PSC Matrix

7
Primary Stroke Center Initiative

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

8
Phoenix Primary Stroke Center Initiative

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

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Phoenix Primary Stroke Center Matrix
Mayo Hospital
Arrowhead
Del Webb
BNI -- St. Josephs
Boswell
SMH Osborn
Banner Thunderbird
Banner Good Samaritan
10
Phoenix Stroke Initiative - Objectives

1. 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.

11
Arizona Cardiovascular Disease State Plan
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Cardiac 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.

13
State 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.

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Long 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

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Long 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.

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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.

17
2005-2008 AZ CV State Plan Activities

• Steering Committee Meeting created to establish
  priorities.
• Statewide CVD Coalition created.

18
CVD Coalition Workgroups

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

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AZ CV Disease State 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)

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Stroke Telemedicine
21
Telemedicine Studies

• Frequent Use tele- medicine for
  stroke1 tele- pathology tele- critical
  care tele- cardiology2 tele- dermatology tele-
  rheumatology tele- psychiatry tele-
  surgery tele- neurosurgery tele- trauma3 tele-
  education tele- correctional care
• Multiple Studies reliability well
  established proof of concept various systems/
  techniques

______________ 1Meyer et al. Neurology.
2005641058-1060. 2Sable et al. Pediatrics.
2002 109. 3Rogers et al. J. Trauma. 2001 51
1037-1041.
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Telemedicine Background
Roine, Ohinmaa Hailey, 2001 Review

• 1124 articles
• 50 reviewed (assessment studies)
• 6 randomized controlled trials
• - procedures sometimes not described
• - outcomes sometimes vague
• - few economic analyses
• - ? no clinical change or saved
• Results
• Evidence for effectiveness is lacking

?
______________ Roine et al.. Canadian Medical
Association Journal. 2001. 165765-771.
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STRokE DOC RCT Telephone VS Telemedicine
rt-PA 24

Trial Completed Manuscript in press
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Optimizing Stroke Care Through Telemedicine

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

• Telemedicine
• Well-established mechanism of providing
  specialized care beyond a hospitals 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

Levine and McConnochie. Neurology.
200769819-820. Meyer et al. Neurology.
2005641058-1060. LaMonte et al. Stroke.
200334725-728
25
Telestroke Facilitates Quality Care
Potential benefits of telestroke

• 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.
200769819-820. Meyer et al. Neurology.
2005641058-1060. LaMonte et al. Stroke.
200334725-728.
26
AHA/ASA Guidelines Support Implementation of
Telestroke in Rural Areas
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.
Adams at al. Stroke. 200738(5)1655-1711
27
Telestroke Real-time Videoconferencing Enables
Efficient Patient Assessment
Video expands and improves upon consultation by
allowing

• 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. 20077913-914.
Shafqat. Stroke. 1999302141-2145
28
Key Trends Driving Telestroke Implementation
Physicians
Hospitals

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

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

Telestroke
Technology
Community

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

• Increasing national and local recognition that
  stroke is under-treated
• Support for telemedicine networks through federal
  and state grants

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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. 20077913-914.
Shafqat. Stroke. 1999302141-2145
30
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Different Models of Telestroke
Third Party Consult
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Increasing and Expanding Telestroke Networks in
Urban and Rural Settings
Colorado Neurological Stroke
Center
Michigan
Stroke Network
Renown Institute for Neuroscience
Utah Telehealth Network
University of Pittsburgh Medical
Center
University of California Los
Angeles
The Maryland Brain Attack
Center
Partners TeleStroke
Center
University of California San
Diego
Mayo Clinic STARR
Medical College of Georgia Remote Evaluation of
Acute Ischemic Stroke (REACH)
University of Texas
Health Sciences Center
33
STRokE DOC Arizona Deployment Phase One
190 miles
Mayo Clinic Hospital Stroke Center
184 miles
34
STRokE DOC AZ TRIAL Stroke Team Remote
Evaluation Using a Digital Observation CameraThe
Initial Mayo Experience

• Hotline activated on 68 occasions as of 7/31/08
• 40 patients enrolled into study randomized to
  either telephone only or video/audio consult
• 35 of consults result in thrombolysis treatment

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STARRStroke 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

36
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

37
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

38
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