By Cong Zhi Zhao, MD
Having lived in rural New Mexico, I know firsthand how difficult it can be to find a specialist such as a neurologist. A consultation often meant a day off from work for patients and a long drive to another part of the state or a neighboring state. In emergencies such as stroke, how can the distance between a stroke specialist and the patient be shortened?
With the prevalence of the internet and videoconferencing hardware, the idea of telemedicine for rural areas has taken off quickly. Telemedicine allows a stroke expert in a distant place to not only talk to a local doctor caring for a stroke patient, but to also see the patient and review her studies including MRI, CT and other laboratory findings.
But is this new modality of medicine really cost effective or are we jumping on the bandwagon without really knowing what it has to offer to our patients? An article in the October 25 issue of the Neurology® journal, titled "The cost-effectiveness of telestroke in the treatment of acute ischemic stroke," looks at telemedicine as it applies to stroke.
This study by Nelson et al. uses computer modeling to calculate the 90-day and lifetime cost-effectiveness of telestroke. They found that compared with usual care across a person's entire lifetime, the cost of telestroke is less than $2,500 per added year of life adjusted for the quality of life. (Called Quality-adjusted life-year or QALY). The threshold of $50,000/QALY is sometimes cited as a cutoff for cost-effective treatments. While the 90-day analysis did not meet this cutoff, the lifetime analysis is significantly under this threshold. The major contributor to the cost of telestroke was the cost of equipment, size of the network, and patient transfer cost.
We must keep in mind that telestroke is not so much a treatment but a delivery system for treatments that have been shown to be effective, such as using medication to dissolve blood clots. This is a tool to guide the local physicians on the best use of this effective medication and to provide the advice to achieve the best functional outcome for a stroke patient.
While the cost of equipment, training and initial set up may be high, this study shows that long term this is a cost-effective way to deliver a needed treatment to stroke patients. With rapid changes in technology, the overall trend will likely be a decrease in the cost of the equipment.
With the increasing number of people being more technology savvy, the training should be easier and faster. Telestroke allows for more accurate consultation than routine telephone calls and increases the appropriate administration of rtPA, the clot dissolving medication. It also addresses the lack of stroke specialists in both rural and underserved urban settings. Moreover, the American Heart Association recommends telestroke use when there are limited resources for acute stroke care.
If telestroke is accepted by insurers and regulators as cost-effective, then reimbursement may be more readily available to cover this vital service for our patients. Telemedicine, at least in the case of telestroke, is a worthwhile investment for those underserved communities.