 |
Dr. Jana Wold, assistant professor of Neur- ology consults with and emergency depart- ment doctor at a rural hospital using the telestroke technology. (Photo courtesy University of Utah Health Care Stroke Center.) |
Telemedicine might be a cost-effective solution for improving stroke patient treatment at rural hospitals that cannot employ a full-time neurologist, a new study shows.
Researchers at the University of Utah Health System in Salt Lake City, Utah in collaboration with researchers at the Mayo Clinic in Phoenix, Arizona, used a complex statistical model to compare the cost-effectiveness of stroke treatment using telestroke in rural emergency departments with stroke treatment provided in similar emergency departments without the 2-way audiovisual system. The study appears in the Sept. 20, 2011 journal Neurology. (Link to published site)
Led by Dr. Jennifer Majersik, assistant professor of neurology at the University of Utah Stroke Center, the researchers developed a decision-analytic model that took into account the cost of treatment using the system and the quality of life following treatment both in the 90 day period post-treatment and over the lifetime of the patient. They compared those costs and benefits with the costs and quality of life of patients treated in rural emergency rooms without the system or a neurologist on staff.
“I wanted to do this study to see, ‘were we doing something that most of us thought was beneficial but were we doing it at too high of a cost,’ Majersik told the Hub in a phone interview, “in which case we should stop. But we weren’t. It turned out it was an extraordinarily cost effective way to provide care.”
Rather than track stroke patients from the initial treatment in the emergency department through discharge, or transfer and then rehabilitation, Majersik said they used the cost and outcomes data that had already been gathered in previous studies and fed them into their statistical model.
“There were a few data points missing from the literature, one of them being the costs of a telestroke network,” Majersik said. “But we are in one, so we know what the costs are, we just haven’t published it, so we pooled data from our network and from the Mayo Clinic network in Phoenix. We used these costs and the outcomes to run the model.”
The model included quality-adjusted life-years (QALYs) gained combined with costs to generate incremental cost-effectiveness ratios (ICERs). The costs were all converted to 2008 dollars. In the lifetime horizon model, both costs and QALYs were discounted at 3 percent annually.
In the initial analysis the researchers ran the model assuming a telestroke stystem with eight rural hospitals and one “hub” or tertiary hospital staffed with four neurologists who rotate telestroke calls either from the hospital or from home telestroke units. They also assumed that each rural hospital would use the system once per month for 12 telestroke consults per year. They also explored a model based on a start-up scenario in which the telestroke network would only have one hub and one to three rural hospitals in the system.
“Twelve (annual consults per spoke) is an average amount for our network, and we polled other hospitals in the area as well,” Majersik said. “We ranged it from 6 to 30 stroke patients. The truth is if you start to have a larger volume of strokes, then you will probably be able to support your own neurologist.”
The analyses were calculated based on total costs of telestroke system, the administration of tissue plaminogen activator (stroke therapy), hospital transfers and caregiver costs and the quality-adjusted life years (QALYs). They compared these costs and the outcomes between hospitals equipped with the telestroke system and those that were not.
The effectiveness outcome of interest in this study was QALYs, which are constructed by multiplying the years of remaining life with the utility weight associated with a certain modified Rankin score (mRS) score. The telestroke incremental cost effectiveness ratio compared to usual care was $108,363 per quality-adjusted life years for the 90 days following treatment, but spread over the remaining lifetime of the patient, the cost was $2,449/QALY.
According to the authors the cutoff for cost effectiveness is generally considered to be $50,000/QALY. Other authors suggest that treatment be considered inexpensive when the incremental cost-effectiveness ratio is $20,000/QALY and expensive when the ratio is $100,000/QALY. Consequently, they concluded that by either standard telestroke was cost-effective when using the lifetime horizon.
“In this study, we have shown that telestroke is more cost-effective in the lifetime horizon, with an ICER of $2,449/QALY, than in the 90-day horizon (ICER of $108,363/QALY),” they wrote. “This divergence of results by time horizon is most likely due to the large up-front fixed costs of telestroke equipment compared to the lifelong benefit of improved quality of life from increased tPA use.”
In an accompanying editorial in the journal Drs. Steven H. Rudolph, MD, Steven R. Levine, of the Department of Neurology at the State University of New York (SUNY), concluded that results suggest that telestroke ought to be considered a appropriate strategy for treating stroke patients in rural community hospitals.
“These results argue strongly for policy change,” they wrote. “Telestroke, as live off-site care, has now been shown to be cost-effective, thus encouraging reimbursement for these services to the same extent as live, on-site care.”
By Michael O'Leary, contributing writer, Health Imaging Hub
No comments:
Post a Comment