Telemedicine using broadband has enabled a faster stroke response with significant savings in Cumbria and Lancashire, as Hedley Emsley and colleagues explain
Stroke is the third largest cause of death in England, and the leading cause of adult disability, with estimated overall costs of £7bn each year, including direct NHS and informal care costs, lost income due to disability and lost productivity.
Intravenous thrombolysis within three hours of stroke onset achieves an improved outcome in one patient for every three treated. The 2007 National Stroke Strategy made clear recommendations for the provision of acute stroke assessment and care, including 24-hour a day, seven-day a week availability of intravenous thrombolysis, a treatment which needs to be given under the supervision of a specialist stroke physician or neurologist.
Different models of care are evolving in order to achieve 24/7 access. In Lancashire and Cumbria, patients are admitted across eight sites and five acute trusts, with long travel times between locations. A telemedicine solution was proposed by the Clinical Advisory Group of the Stroke Network in Lancashire and Cumbria, with a virtual hub for out of hours coverage, using broadband technology to connect hospitals with a remote network of stroke specialists and enabling the physician (based at home outside working hours) to carry out a live consultation with the patient and local medical teams and to see CT scans.
Potential cost savings from 24/7 thrombolysis were modelled using results from the SITS-MOST study, a prospective European registry assessing safety of thrombolysis in clinical practice compared with clinical trials (figures 1 and 2).
This modelling was based on a 10 per cent thrombolysis rate among 4,000 patients annually in Lancashire and Cumbria having a stroke, ie 400 patients eligible for thrombolysis. Based on this model, each year we would expect 24 more patients to be alive, 40 additional patients to have either no symptoms or no significant disability, and 36 fewer patients to be dependent (using modified Rankin Scale 3, 4 or 5).
The National Stroke Strategy Impact Assessment identified cost savings of £30,000 per independent stroke survivor per year and a 10-year cost for dependent stroke of £56,381. Our modelling suggested that 24/7 thrombolysis would achieve 60 additional independent stroke survivors (mRS 0, 1 or 2) per year within Lancashire and Cumbria.
The potential cost saving would therefore be £1.8m per year and £18m over 10 years. The potential cost saving associated with 36 fewer dependent stroke survivors (mRS 3, 4 or 5) each year would be 36 x £56,381 or £2.03m over 10 years. As a result, 24/7 thrombolysis could be associated with potential total cost savings of £20.3m over 10 years.
£1m per year savings
Given that 50 per cent of patients are expected to present out of hours, the proposed telemedicine solution would be expected to save approximately £1m per year across Lancashire and Cumbria.
An options appraisal identified five commissioning options:
- Do nothing
- Await incremental change by individual providers
- Develop a hyperacute centre
- Use telestroke out of hours via a network rota
- Use telestroke via an outsourced supplier.
Costs (table 1), benefits and risks associated with each of these options were considered. Option 4 was favoured for many reasons including its likely timely delivery, equity of access and network-wide collaboration with a potential rota of stroke physicians and neurologists.
Implementation work is well advanced, with North Cumbria University Hospitals Trust as the lead provider. Workstreams include procurement and implementation of IT infrastructure, communication plans to raise awareness of stroke, negotiations on consultant job plans, establishment of a telestroke pathway on each site, clinical governance arrangements for cross-organisational working, development of a telestroke operational policy and staff training.
IT set-up costs are being funded by a £250,000 award from the NHS regional innovation fund for the North West. Development of a standardised telemedicine toolkit is also under way as part of a related £250,000 National Institute of Health Research collaborative research project between the Lancashire Teaching Hospitals Foundation Trust, the University of Central Lancashire and the Stroke Network in Lancashire and Cumbria.
Hedley Emsley is a consultant neurologist and honorary lecturer, Lancashire Teaching Hospitals Foundation Trust. Kathy Blacker is network director, Cardiac and Stroke Networks in Lancashire and Cumbria. Paul Davies is a consultant stroke physician, North Cumbria University Hospitals Trust. Mark O’Donnell is a consultant stroke physician, Blackpool, Fylde and Wyre Hospitals Foundation Trust.
- Consider limiting factors specific to local service delivery, eg geography, physical versus virtual hub and spoke models
- Review manpower resources, eg expansion in number of specialist stroke physicians for each site versus use of network “pool” across multiple sites
- Ensure collaborative working involving all relevant stakeholders, thereby facilitating commissioning, technology, governance arrangements, etc
- Explore all available funding options, eg funding streams specific to healthcare innovation
- Facilitate any additional training, eg training and assessment programme in acute stroke CT brain scans
- Work with partner organisations to explore clinical-academic collaborations