Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program

Abstract

Aims: Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective.

Methods: A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not.

Results: The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3 h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952–$4,438) per patient and increase QALYs by 0.20 (0.14–0.22). This increase in QALYs equates to ∼73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model.

Conclusion: The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).

Keywords:

• Cost effectiveness
• stroke
• stroke care
• telemedicine
• patient transport
• tPA
• rural healthcare

Notes

Transparency

Declaration of funding

This publication was made possible by Grant Number 1C1CMS331351 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors, and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

Declaration of financial/other relationships

The authors are employees of the University of New Mexico. Peer reviewers on this manuscript have received an honorarium from JME for their review work, but have no other relevant financial relationships to disclose.

Acknowledgments

No assistance in the preparation of this article is to be declared.

Notice of correction

Please note that Figure 2 has been amended since the paper was first published online (19 January 2018).

Notes

1 The total number of possible outcomes is 56.

2 While the standard of care for tPA is the 3-h mark, some studies have shown effectiveness of tPA up to the 4.5-h mark. Additional analysis was done, moving the time of a stroke specialist reading a patients CT/MRI imaging from 3-h to 4.5-h. These results were similar, with slightly greater cost savings.