Demaerschalk, Bart M.

Introduction: Prehospital telestroke is increasingly utilized in mobile stroke units and telemedicine-enabled ambulances for acute ischemic stroke (AIS). While the NIHSS remains the standard for telestroke assessment, simpler scales have been validated to help paramedics recognize large vessel occlusion (LVO) strokes but have not been evaluated in a traditional telestroke network. We aimed to determine the accuracy of common LVO scales in a large academic telestroke practice. Methods: This retrospective study included all telestroke consults performed in a large academic telestroke network from 2019 to 2020. Patients were excluded if no NIHSS or vessel imaging was performed. We recorded presenting NIHSS, site of vessel occlusion, and discharge diagnosis. LVO was defined as an acute occlusion of the internal carotid artery and/or M1 middle cerebral artery. The NIHSS was used to calculate 7 LVO scales (RACE, C-STAT, FAST-ED, 3I-SS, PASS, VAN, and G-FAST). Diagnostic performance was assessed by calculating sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy using the established thresholds of each scale. These results were compared to NIHSS at thresholds of 6, 8, and 10. Area under curve (AUC) was calculated using c-statistics by treating scales as continuous variables. Results: A total of 625 patients were included, 373/625 (59.7%) of which were diagnosed with AIS at discharge. LVO was identified in 78/625 (12.5%) patients. VAN was the most sensitive prehospital stroke scale (83.3%), whereas 3I-SS ≥ 4 was the most specific (95.2%). Both the RACE and FAST-ED scales demonstrated superior accuracy and AUC compared to the NIHSS (Table 1). Conclusions: To our knowledge, this is the first study assessing LVO scale accuracy in a large telestroke network. As use of prehospital telestroke grows, this study highlights several scales that may allow for faster prehospital triage decisions without sacrificing accuracy.

Introduction: Telestroke facilitates emergent assessment of patients with suspected acute ischemic stroke (AIS) to identify candidates for acute interventions. The diagnostic accuracy of the telestroke consultation of a large academic hub and spoke telemedicine network has yet to be investigated. The goal of our study is to determine the diagnostic accuracy of the initial telestroke consultation. Methods: This is an IRB-exempt retrospective study including all patients evaluated for cerebral ischemia via video telestroke consultation in a large academic hub and spoke telemedicine network from 2019 to 2020. Detailed chart review was conducted to identify initial suspected diagnosis and final diagnosis. Cerebral ischemia was defined as AIS and transient ischemic attack (TIA). All other diagnoses were defined as stroke mimics. Data was organized into continuous and categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, area under the curve (AUC) and likelihood ratio (LR+) for the initial telestroke consultation diagnosis were calculated while using the final diagnosis as the gold standard diagnosis. Results: A total of 1043 patients met inclusion criteria. Final diagnosis of cerebral ischemia was made in 63.5% of all patients (539/1043 with AIS,123/1043 with TIA). Stroke mimic was diagnosed in 36.5% patients (381/1043). The sensitivity and specificity of telestroke evaluation for diagnosis of cerebral ischemia were 97.1% and 81.4%, respectively. PPV was 90.1%, and NPV was 94.2%. Overall diagnostic accuracy was 91.4% with a LR+ of 5.21 and AUC of 0.89. The most common stroke mimics were metabolic encephalopathy (13.7%, 52/381), migraine (10.8%, 41/381) and seizure (10.5%, 40/381). Conclusions: This study highlights the high diagnostic accuracy of telestroke providers to diagnose cerebral ischemia and stroke mimic in a large academic hub and spoke network. Further research is needed to investigate methods to improve our diagnostic accuracy further, as well as explore the application of tele-neurology in the non-stroke setting.

Telemedicine approaches provide many benefits to patients across both primary and specialty care. Patient acceptance is imperative to successful telemedicine implementation. As telemedicine utilization continues to surge, it is imperative that healthcare organizations have a method for evaluating the patient experience with these types of visits. Previous studies on experience with telemedicine have focused on smaller patient populations with narrow inclusion criteria and limited geographical reach. This research described how patients’ satisfaction with video telemedicine-based visits varied based on patient characteristics and how they compare with in-person visits. We obtained and analyzed results from standardized patient experience surveys to compare telemedicine and in-person clinic visits during the COVID-19 pandemic (between July 1, 2020, and June 30, 2021) across a diverse patient population. During the study timeframe, surveys were sent to 1,521,398 patients with a response rate of 20% (307,185). Our organization’s unique structure, size, and geographic spread allowed for a deeper and more comprehensive examination of telemedicine participants. Though a few trends emerged in the results, there were no significant differences in patient ratings of telemedicine visits and in-person clinic visits during the same period (p=0.672). This study demonstrated that patient satisfaction with telemedicine visits was non-inferior to in-person outpatient visits during the study timeframe. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

ImportanceThere was a shift in patient volume from in-person to video telemedicine visits during the COVID-19 pandemic.ObjectiveTo determine the concordance of provisional diagnoses established at a video telemedicine visit with diagnoses established at an in-person visit for patients presenting with a new clinical problem.Design, Setting, and ParticipantsThis is a diagnostic study of patients who underwent a video telemedicine consultation followed by an in-person outpatient visit for the same clinical problem in the same specialty within a 90-day window. The provisional diagnosis made during the video telemedicine visit was compared with the reference standard diagnosis by 2 blinded, independent medical reviewers. A multivariate logistic regression model was used to determine factors significantly related to diagnostic concordance. The study was conducted at a large academic integrated multispecialty health care institution (Mayo Clinic locations in Rochester, Minnesota; Scottsdale and Phoenix, Arizona; and Jacksonville, Florida; and Mayo Clinic Health System locations in Iowa, Wisconsin, and Minnesota) between March 24 and June 24, 2020. Participants included Mayo Clinic patients residing in the US without age restriction. Data analysis was performed from December 2020 to June 2021.ExposuresNew clinical problem assessed via video telemedicine visit to home using Zoom Care Anyplace integrated into Epic.Main Outcomes and MeasuresConcordance of provisional diagnoses established over video telemedicine visits compared against a reference standard diagnosis.ResultsThere were 2393 participants in the analysis. The median (IQR) age of patients was 53 (37-64) years; 1381 (57.7%) identified as female, and 1012 (42.3%) identified as male. Overall, the provisional diagnosis established over video telemedicine visit was concordant with the in-person reference standard diagnosis in 2080 of 2393 cases (86.9%; 95% CI, 85.6%-88.3%). Diagnostic concordance by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision chapter ranged from 64.7% (95% CI, 42.0%-87.4%) for diseases of the ear and mastoid process to 96.8% (95% CI, 94.7%-98.8%) for neoplasms. Diagnostic concordance by medical specialty ranged from 77.3% (95% CI, 64.9%-89.7%) for otorhinolaryngology to 96.0% (92.1%-99.8%) for psychiatry. Specialty care was found to be significantly more likely than primary care to result in video telemedicine diagnoses concordant with a subsequent in-person visit (odds ratio, 1.69; 95% CI, 1.24-2.30; P < .001).Conclusions and RelevanceThis diagnostic study of video telemedicine visits yielded a high degree of diagnostic concordance compared with in-person visits for most new clinical concerns. Some specific clinical circumstances over video telemedicine were associated with a lower diagnostic concordance, and these patients may benefit from timely in-person follow-up.

Introduction: Intravenous alteplase (tissue plasminogen activator) has been shown to be cost-effective due to savings in long-term disability. In October of 2005, an increased DRG payment to hospitals for alteplase-treated stroke patients was introduced. We sought to describe the trends in the cost of alteplase over time, in comparison to trends in hospital reimbursement in the United States. Methods: Utilizing publicly available information on the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov), we obtained CMS quarterly payment amounts between 1/1/2005-10/1/2014 for alteplase, listed as “alteplase recombinant, per mg.” CMS payment amounts are the manufacturer’s average sales price (ASP) + 6% until 4/2014, when it was lowered to + 4.3%. Estimates for DRG base payments were calculated within MEDPAR for FY 2006 (DRG 559) and 2013 (MS DRGs 61,62, and 63) as: (DRG relative weights) x (standardized operating and capital amount). The Consumer Price Index (CPI) was also queried for all prescription drugs, urban areas, during the same study period as reference. Results: The CMS payment amount for alteplase/mg was $30.50 in 1/2005, and $64.30 in 10/2014. Trends in the CMS payment amounts for alteplase increased by 111% between 2005-2014, shown in the Figure. The CPI for all prescription drugs increased by 30.2% in the same time frame. The base payment for alteplase-treated stroke admissions was $11,173 in 2006, and $12,064 in 2013, an 8% increase. Discussion: We found a striking increase in the cost of alteplase over the last decade, with a 100mg vial now with a CMS payment of ∼$6400, a more than 100% increase over ten years. During the same timeframe, the DRG base payment to hospitals increased by only 8%, and alteplase cost increased from 27% of the payment in 2006 to 53% in 2013. Researchers and stroke physicians should be aware of these changes in drug costs and their impact on cost-effectiveness analyses.

Background: Each year, nearly 700,000 Americans suffer from strokes, resulting in 150,000 deaths and significant disability among survivors. Despite advances in therapeutic options for acute stroke within a critical time window, patient delay in seeking medical attention remains a significant barrier to improving outcomes. In a recent study of the effect of marital status on the timing of presentation for medical care in patients with chest pain, married men presented earlier than married women. In this study, we hypothesize that marital status is a predictor of earlier health-seeking behavior following the onset of stroke symptoms. Methods: We conducted a retrospective review of 100 patients with acute stroke symptoms in our stroke alert quality initiative database who were brought by Emergency Medical Services (EMS) to the Mayo Clinic Hospital, Arizona between December 1, 2010 and June 30, 2011. Nine patients were excluded due to lack of data. The database contains the following information for each patient: age, gender, marital status, the time of symptom awareness, and the time of EMS dispatch. Using both an independent samples t-Test and ANOVA, we compared the time from symptom awareness to EMS dispatch both between married and single patients, and between men and women, (married and single). Results: The mean age of the 91 patients studied was 76 years (SD = 12.5 years) and 52% were women. Forty-five patients (49.5%) were married, and 46 (50.5%) were single. The mean time from symptom awareness to EMS activation was 52 minutes (median 21.0, SD 87.3, range 2-519 minutes.) Categorized by marital status, married patients activated EMS earlier that single patients, but this difference was not significant (43 versus 60 minutes, p=0.35.). Analyzing the data separately for gender, we found that married men activated EMS significantly earlier than married women (26 versus 72 minutes, p=0.04.). Single men activated EMS earlier than single women, but this difference was not significant (50 versus 66 minutes, p=0.60.) Conclusions: Among persons with acute stroke symptoms, earlier medical-seeking behavior was seen in married compared to single persons, and particularly in married men. We plan to analyze a larger sample of patients, and if these preliminary findings are confirmed, we will conduct a prospective study evaluating reasons why married men with stroke symptoms seek medical attention earlier.

Abstract Virtual care, introduced previously as a replacement for in-person visits, is now being integrated into clinical care delivery models to complement in-person visits. The COVID-19 pandemic sped up this process. The rapid uptake of virtual care at the start of the pandemic prevented educators from taking deliberate steps to design the foundational elements of the related learning environment, including workflow, competencies, and assessment methods. Educators must now pursue an informed and purposeful approach to design a curriculum and implement virtual care in the learning environment. Engaging learners in virtual care offers opportunities for novel ways to teach and assess their performance and to effectively integrate technology such that it is accessible and equitable. It also offers opportunities for learners to demonstrate professionalism in a virtual environment, to obtain a patient’s history incorporating interpersonal and communication skills, to interact with multiple parties during a patient encounter (patient, caregiver, translator, telepresenter, faculty member), to enhance physical examination techniques via videoconferencing, and ideally to optimize demonstrations of empathy through “webside manner.” Feedback and assessment, important features of training in any setting, must be timely, specific, and actionable in the new virtual care environment. Recognizing the importance of integrating virtual care into education, leaders from across the United States convened on September 10, 2020, for a symposium titled, “Crossing the Virtual Chasm: Rethinking Curriculum, Competency, and Culture in the Virtual Care Era.” In this article, the authors share recommendations that came out of this symposium for the implementation of educational tools in the evolving virtual care environment. They present core competencies, assessment tools, precepting workflows, and technology to optimize the delivery of high-quality virtual care that is safe, timely, effective, efficient, equitable, and patient-centered.

Introduction: Teleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs. Objective: To evaluate the cost of TN from the perspective of the health care system. Methods: We constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted. Results: For neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual care <12% (base-case = 82%), TN reducing the odds of transfer by <8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient). Conclusions: Economic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.