Telemedicine to Treat Rural Stroke Patients via a Hub-and-Spoke Model

Background: Telemedicine is a model of care that is becoming known for its patient-centric and environmentally friendly applications.1Combining telemedicine with a hub-and-spoke model is a method being used more frequently to disseminate vascular expertise and optimize recombinant tissue plasminogen activator (rt-PA) use.2Approximately 45% of Americans do not have immediate access to acute stroke centers within 60 minutes.4 Due to this distance and time between onset and arrival, patients presenting to rural emergency departments are 10 times less likely to receive rt-PA than those same patients in urban settings. Telemedicine is one method that can be used to provide more accurate decisions regarding rt-PA, while a hub-and-spoke model can be used to reduce hospital and societal costs, along with the time between onset and presentation. Methods: An exhaustive literature search using MEDLINE-PubMed, CINAHL, Google Scholar, and Web of Science using the search words telestroke, rural patients, and hub-and-spoke. Inclusion criteria were restricted to rural patients who received stroke care via telemedicine and a hub-and-spoke model. Selected studies were restricted to English only. Utilizing the GRADE criteria, all relevant articles were assessed for quality.8 Results: 3 articles met inclusion criteria for this systemic review. Two articles focused solely on cost effectiveness. Significant network cost savings of $358,435 annually over a 5-year time horizon were observed, while patients incurred lifetime savings of $1436. The third study2demonstrated significantly improved data collection, decision making, and increased rt-PA administration rates when comparing telemedicine and telephone consults. Conclusion: Combining telemedicine technologies with a hub-and-spoke model results in cost savings for both the institution and patient. In addition, patients experience a slight improvement in overall QALY (quality adjusted life years). Secondly, utilizing telemedicine resulted in more complete data collection, more accurate decision making regarding administration of rt-PA, and higher administration rates. Despite the significant results in decision making and data collection, insignificant findings regarding select secondary outcomes warrant a larger study to better assess differences in 90-day patient outcomes