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The American Journal of Managed Care December 2013
Implementing Effective Care Management in the Patient-Centered Medical Home
Catherine A. Taliani, BS; Patricia L. Bricker, MBA; Alan M. Adelman, MD, MS; Peter F. Cronholm, MD, MSCE, FAAFP; and Robert A. Gabbay, MD, PhD
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Cost Utility of Hub-and-Spoke Telestroke Networks From Societal Perspective
Bart M. Demaerschalk, MD, MSc; Jeffrey A. Switzer, DO; Jipan Xie, MD, PhD; Liangyi Fan, BA; Kathleen F. Villa, MS; and Eric Q. Wu, PhD
Economics of Genomic Testing for Women With Breast Cancer
Robert D. Lieberthal, PhD
Impact of Electronic Prescribing on Medication Use in Ambulatory Care
Ashley R. Bergeron, MPH; Jennifer R. Webb, MA; Marina Serper, MD; Alex D. Federman, MD, MPH; William H. Shrank, MD, MSHS; Allison L. Russell, BA; and Michael S. Wolf, PhD, MPH
Medication Utilization and Adherence in a Health Savings Account-Eligible Plan
Paul Fronstin, PhD; Martin-J. Sepulveda, MD; and M. Christopher Roebuck, PhD, MBA
Characteristics of Low-Severity Emergency Department Use Among CHIP Enrollees
Justin Blackburn, PhD; David J. Becker, PhD; Bisakha Sen, PhD; Michael A. Morrisey, PhD; Cathy Caldwell, MPH; and Nir Menachemi, PhD, MPH
Collection of Data on Race/Ethnicity and Language Proficiency of Providers
David R. Nerenz, PhD; Rita Carreón, BS; and German Veselovskiy, MS
Dietary Diversity Predicts Type of Medical Expenditure in Elders
Yuan-Ting Lo, PhD; Mark L. Wahlqvist, MD; Yu-Hung Chang, PhD; Senyeong Kao, PhD; and Meei-Shyuan Lee, DPH

Cost Utility of Hub-and-Spoke Telestroke Networks From Societal Perspective

Bart M. Demaerschalk, MD, MSc; Jeffrey A. Switzer, DO; Jipan Xie, MD, PhD; Liangyi Fan, BA; Kathleen F. Villa, MS; and Eric Q. Wu, PhD
A cost-utility analysis of a hub-and-spoke telestroke network showed that it was economically dominant over routine care.
Background: A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve patient outcomes.

Objectives: To evaluate the cost utility of a telestroke network in the management of acute ischemic stroke from the societal perspective.

Study Design and Methods: A lifetime Markov model was developed to compare the incremental costs and effectiveness of a telestroke network. One-year transition probabilities between the 3 health states based on the modified Rankin scale—minimal-to-no disability, moderate-to-severe disability, and death—were derived from literature. Costs included telemedicine setup and maintenance, initial and recurrent stroke treatment, rehabilitation, long-term care, and caregiver costs. Effectiveness was defined as quality-adjus ted life-years (QALYs). Model inputs were obtained from the literature supplemented by data from Georgia Health Sciences University and Mayo Clinic. The base case network included 1 hub and 7 spokes, and assumed no survival benefits from acute treatment in a network. One-way sensitivity analyses were conducted.

Results: Compared with no network, patients treated in a telestroke network incurred $1436 lower costs and gained 0.02 QALYs over a lifetime. Incremental costs decreased from $444 for the first year to –$1436 over a lifetime; incremental QALYs increased from 0.002 for the first year to 0.02 over a lifetime. Overall, results were robust in the 1-way sensitivity analyses. A telestroke network became less cost-effective with increasing spoke-to-hub transfer rates.

Conclusions: A telestroke network is cost savingand more effective compared with no network from the societal perspective in most modeled scenarios.

Am J Manag Care. 2013;19(12):976-985
This health economic study demonstrated that compared with a rurally located patient receiving routine stroke care at a community hospital, a patient treated in a telestroke network incurred $1436 lower costs and gained 0.02 quality-adjusted life-years over a lifetime.
  • The telestroke network was economically dominant over routine care. n The results serve to inform government organizations, insurers, healthcare institutions, practitioners, patients, and the general public that an up-front investment in telemedicine and stroke network personnel can be justified in our health system.

  • Insurance plans should reimburse telestroke consultations in the same fashion as face-to-face clinical encounters.
Stroke is a leading cause of severe disability, and the fourthleading cause of death in the adult population in the United States.1,2 Acute ischemic stroke (AIS) accounts for more than 80% of all strokes.3 Administration of intravenous (IV) thrombolysis within a 3-hour window of the onset of AIS reduces disability.4 A recent clinical trial has demonstrated that IV thrombolysis administered between 3 and 4.5 hours after the onset of AIS could also significantly improve clinical outcome.5 Extending the 3-hour traditional   time window by 1.5 hours is likely to increase the demand for IV thrombolysis because more AIS patients would present to the hospitals in time for treatment.

Despite the effectiveness of IV thrombolysis, fewer than 5% of patients who suffer AIS in the United States receive IV thrombolysis.6 One of the major barriers to IV thrombolysis administration is that most hospitals do not have the resources required to enable timely diagnosis and treatment of AIS patients. Hospitals with access to qualified personnel (eg, 24/7 on-call vascular neurologists) are most likely to provide care due to the time limitation. However, it is not feasible for every hospital to meet such resource and personnel requirements, especially those in remote rural areas. To serve communities without a stroke center, telestroke referral networks have been set up to connect a stroke center (the hub hospital) with local hospitals (spoke hospitals) and thus extend the reach of the acute stroke care team of the hub hospital to spoke hospitals. Through this establishment, AIS patients can receive  more accurate diagnoses, more correct thrombolysis eligibility determination, and more appropriate emergency treatment, all resulting in potentially better prognoses. For instance, research studies revealed that telestroke results in correct diagnosis and thrombolysis decision making in 96% of instances.7

A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve  patient outcomes. The costs associated with these networks, as well as the health-related outcomes, must be considered. We previously conducted a cost-effectiveness analysis (CEA) from the hospitals’ perspective.8 Building on that model,8 the current study aimed to assess the cost utility of a hub-and-spoke telestroke network compared with no network (absence of regional stroke system of care and telemedicine) in the management of AIS from the societal perspective. Two such studies were published and subsequently independently appraised and scored by the Tufts Medical Center Cost Effectiveness Analysis Registry.9,10 However, our study was the first to develop a cost decision model that included the possibility of endovascular therapy in addition to IV thrombolysis and the first to include an expanded array of cost inputs associated with dedicated network program managers and personnel, higher estimates of inpatient care, inter-hospital transfer, rehabilitation, long-term care, and caregiver costs, as well as a wider range of spoke-to-hub transfer rates, using 2 independent telestroke network data input sets.


Model Overview

A Markov model was developed to estimate the incremental costs and effectiveness with and without a telestroke network for the management of AIS over a lifetime. The model had 3 health states defined by the modified Rankin scale (mRS)11: (1) minimal-to-no disability (mRS 0-2); (2) moderate-to-severe disability (mRS 3-5); and (3) death (mRS 6). A hypothetical cohort of AIS patients with a mean age of 68 years were assumed to receive acute care in a telestroke network versus a no-network setting and to transition between these health states at the beginning of each cycle (1 year). The mean age of 68 years was obtained from a US epidemiology study of patients with first-time stroke.12 Figure 1 illustrates the decision and treatment process for AIS and subsequent transitions. Building on the previous model,8 the base case of this study modeled a network with 1 hub and 7 spokes, with a total of 1112 unique AIS patients presenting to emergency departments in the network hospitals per year. The number of spoke hospitals in the network was based on a recent survey of active telestroke networks by Silva and colleagues,13 and the average number of AIS patients for spoke hospitals was obtained from the Georgia Health Sciences University and the Mayo Clinic telestroke networks. The number of AIS patients for the hub hospital was assumed to be 400 , based on the typical size of a hub hospital. Data on network characteristics were obtained from the Georgia Health Sciences University and the Mayo Clinic telestroke networks (see eAppendix available at; these data were described in a study based on the same network.8 The following assumptions were made in the model estimation:

  • Acute ischemic stroke patients could only transition from a less severe to a more severe health state or remain in the same health state at each cycle.
  • Stroke treatments between a telestroke network and no network differed only during the initial hospitalization for AIS, not after discharge from acute care.
  • Incremental effectiveness associated with treatments in a telestroke network only resulted from IV thrombolysis or endovascular stroke therapy during the initial hospitalization for the first-time AIS.
  • There was no difference in stroke-related mortality between patients with and without IV thrombolysis,and between patients with and without endovascular stroke therapy during hospitalization. We made these assumptions because clinical trials on IV thrombolysis did not show a significant difference in mortality between patients who received IV thrombolysis and patients who did not, though the former group had a numerically lower rate.4,14 In addition, there was also a lack of randomized controlled trial data comparing the efficacy of endovascular stroke therapy with no such therapy.15,16 Therefore, we assumed no mortality difference in mortality in the base case, which could be a conservative assumption.
  • Rate of recurrent stroke was the same regardless of the treatment received during the initial hospitalization for AIS.
Model Inputs

Model inputs included 3 major groups: health state distributions, costs, and utilities.

Health State Distributions

Health state distributions at the end of each cycle were decided by the initial health state distribution and transition probabilities per cycle. The initial health state distribution was based on mRS at 3 months, which was determined by the type of acute treatment for AIS (ie, IV thrombolysis, endovascular stroke therapy). Although mRS can change within the first year of AIS, it tends to stabilize after 3 months.17 Therefore, mRS at 3 months was a good proxy for the health state for the first year among AIS patients. Data on mRS at 3 months for IV thrombolysis with different onset-to-treatment times and endovascular stroke therapies were obtained from clinical trials,14-16 and were adjusted based on the assumption that mortality was the same for patients with versus without IV thrombolysis and for those with endovascular stroke therapy versus without endovascular stroke therapy (see eAppendix).

Transition probabilities (Table 118-29) were estimated based on recurrent stroke rate and mRS after recurrent strokes. Recurrent stroke rate was different for the first year after stroke and subsequent years.24 Modified Rankin scale distribution after recurrent strokes for patients with minimal  to no disability was assumed to be the same as that among first-time AIS patients without IV thrombolysis and endovascular stroke therapy.14,30 Recurrent stroke increased the mortality rate among patients with moderate-to severe disability compared with those with minimal to no disability.30 Because the post acute stroke treatments did not differ between a telestroke network and no network, the transition probabilities after first-time AIS were the same for the 2 settings. In  addition, all patients transitioned to death based on the age-specific natural death rate reported for the US general population.31

Cost Inputs

Costs included the following components: (1) telestroke setup and maintenance costs, (2) initial hospitalization costs, (3) post acute stroke care costs (including rehabilitation and nursing home costs), and (4) caregiver costs, which were obtained from the literature and publicly available data (Table 1). Rehabilitation costs (both inpatient and others) were onetime costs assumed to occur after each episode of stroke. Nursing home costs and caregiver costs were incurred as long as patients were alive. All cost inputs were inflated to 2011 US dollars using the medical care services component of the Consumer Price Index.29

Utility Inputs

Utility values associated with minimal to no disability and moderate to severe disability among stroke patients, as measured by the EuroQol, were obtained from the literature.23 Death was assumed to have a utility of 0.

Model Outputs

Model outputs included total incremental costs, incremental effectiveness outcomes, and incremental cost-effectiveness ratios (ICERs) comparing an AIS patient treated within a telestroke network with an AIS patient treated outside a telestroke network. Total incremental costs included all com-ponents described above and were summed across all model cycles. Incremental effectiveness was measured as qualityadjusted life-years (QALYs), calculated as life years spent in each health state weighted by the utility of that health state. Cost and effectiveness outcomes were discounted at 3% per year in the base case.

Sensitivity Analysis

To determine whether the results were sensitive to certain parameters in the model, 1-way sensitivity analyses were performed by varying 1 model input at a time while holding other model inputs at the base case values. Parameters included in the sensitivity analyses were (1) annual recurrent stroke rate in the first year and subsequent years; (2) transition probability of disability or death after recurrent strokes; (3) utility inputs; (4) inpatient rehabilitation costs, other rehabilitation costs, and nursing home costs; (5) caregiver costs; (6) setup and maintenance costs of telestroke systems; and (7) network characteristics (eg, number of spoke hospitals, spoke-to-hub transfer rate, IV thrombolysis rate, endovascular stroke therapy rate among transferred patients). The majority of inputs were varied within plus or minus 25% of the base case values, except for inpatient rehabilitation costs among stroke patients with minimal-to-no disability, in which case 5% and 10% utilization rates were assumed. A 2-way sensitivity analysis was also performed by varying both spoke-to-hub transfer rate (from 0% to 100%) and endovascular stroke therapy rate among transferred patients (with 25% and 50% of the base case value).


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