Delivering acute stroke care to regional Victoria: The Victorian Stroke Telemedicine Program Dr Kathleen Bagot - Research Fellow @KatieBagot Prof Chris Bladin – Program Lead (Clinical) @VSTprogram A/P Dominique Cadilhac – Program Lead (Research) @DominiqueCad “Rural Matters” Gippsland Acute Care Symposium 25 November 2016

Stroke Leading cause of death and disability Physical and psychological impact 50,000 new strokes in Australia every year 13,000 in Victoria 30% outside metropolitan area Treatment is time critical Challenges for regional areas

Telemedicine a solution TEMPiS – Germany 15 hospitals ASTUTE – UK 8 hospitals REACH – Georgia USA over 10 years STRokE DOC – California, Arizona USA GWTG – USA – over 1700 hospitals

Aims of the VST Program Increase equity of access to expert care Improve access to time-critical therapies Improve diagnosis and treatment timelines Evaluate cost-effectiveness of acute stroke telemedicine Contribute to the development of acute telestroke services in Australia Patients are eligible if presenting within 4.5 hours of symptom onset to regional hospitals

Stroke distribution in Victoria isochrone map - suspected strokes - thrombolysis centre 3 hour drive time to Melbourne 1 hour drive time to regional centre 94% of suspected strokes located within 60 minutes of thrombolysis centre Mapped out location of strokes occurring in Victoria treatment centres Drive times of 1 hour to a treatment centre is in blue Drive times of 3 hours to a treatment centre is in pink Allowed us to determine hospitals to include in the VST Program

VST Program Hospitals Mildura Swan Hill Albury-Wodonga Echuca Horsham Shepparton Albury-Wodonga Traralgon Bairnsdale Warrnambool Horsham Hamilton Bendigo Warragul Ballarat Wonthaggi Sale Wangaratta VST will be in 16 hospitals across Victoria While all specialists on call are based in Melbourne All sites received a teledoc – this is a fully integrated system allowing audio-visual interaction between regional site and metropolitan specialists Allowed specialists to liaise direct with clinician or indeed direct with patient or family, as relevant All sites also have a part-time project co-ordinator who is tasked with implementing VST within their hospital, including training staff and data collection Usually someone from within the hospital with a clinical background

How the VST Program works Stroke symptom onset < 4.5 hours Regional Hospital Phone 1300 TELEMED Paramedics notify hospital Rapid triage and assessment CT brain and CTA Acute stroke therapies delivered within acceptable timeframe - tPA, ECR - Video consultation with family and regional clinician Rapid review of brain imaging remotely Assessment by VST stroke specialist

30% of cases are not stroke ie actually making a diagnosis is very important!! 20% results in tPA 30% get ECR – this is worlds best practice!! During October, there were 112 VST consultations (28 recommended for stroke thrombolysis, 6 recommended for ECR).

National Stroke Foundation Audit 2009 National Stroke Foundation Audit Comparable thrombolysis rates Thrombolysis National Stroke Foundation Audit 2009 National Stroke Foundation Audit 2015 Australia Regional Size (75-199) VST Program All Ischaemic 8% 2% 5% 10% Ischaemic < 4.5 hrs not reported 24% 16% 34% Preliminary VST data

Treatment delivered safely Confirmed stroke & received stroke thrombolysis Pre-VST N=85 n (%) VST N=98 p TEMPiS 2006 (Germany) sICH (bleed) 12 (14%) 5 (5%) 0.04 9% Deceased (in hospital) 16 (19%) 12 (12%) 0.07 10% Preliminary VST data

6703 days of healthy life gained Faster clinical processes Equivalent to 6703 days of healthy life gained or 18.4 years (based on paper Meretoja A, et al, Stroke 2014 Stroke, 45(4), 1053-1058) Ischaemic strokes and received thrombolysis Reduction in time (median minutes) Pre-VST N=85 VST N=98 p value Median mins (Q1, Q3) ED Door to CT time 2 mins 22 (11, 38) 20 (15, 29) 0.471 ED Door to thrombolysis time 25 mins 102 (77, 129) 77 (60, 103) <0.001 Stroke onset to needle time 38 mins 213 (170, 257) 175 (135, 215) Preliminary VST data

Cost effective Preliminary economic modeling $50,000 per healthy year gained threshold for cost-effectiveness Compared to usual care Incremental cost per healthy year gained $37,692 (95% uncertainty range from sensitivity analysis) ($22,336, $59,806) Preliminary VST data

VST Program success summary Increased access to specialists Faster clinical processes Comparable thrombolysis rates Safer treatment delivery Benefits to patients Cost effective model Removed the barrier of distance for health care Changed the way health care delivered

3550 So, no matter where you live in Vic, no matter your postcode, you can get access to high quality acute stroke care and, if needed, transfer to RMH for ECR. 3865 3280

VST Acknowledgements Project Leads: Christopher Bladin, Dominique Cadilhac Steering and Management Committee members including Chair of Steering Committee: Geoff Donnan Members of the VST Working Groups: Medical, Communication & Education, IT, Financial Sustainability, Research & Evaluation VST Neurologists: Bruce Campbell, Helen Dewey, Richard Gerraty, Amanda Gilligan, Peter Hand, Poh-Sien Loh, Tom Oxley, Marion Simpson, Hans Tu, Teddy Wu, Nawaf Yassi, Philip Choi, Jorge Zavala Hospitals: Bendigo Health, Echuca Regional Health, Mildura Base Hospital, Swan Hill District Health, Goulburn Valley Hospital, Northeast Health Wangaratta, Albury Wodonga Health, Wimmera Health Care Group, Latrobe Regional Hospital, Central Gippsland Health Service, Bairnsdale Regional Health, Ballarat Health Services, West Gippsland Healthcare Group, South West Healthcare, Bass Coast Health, Western District Health Service Site co-ordinators: Justin Rabl, Trudi Hill, Anne van Berkel, Casey Hair, Mick O’Shea, Janette McCabe, Catharina de Muelenaere, Lisa Howard, Julie Stevens, Ashley Murray, Pat Groot, Janet May (Former: Sharan Ermel, Jo Cottrell, Lisa Peters, Lauren Arthurson, Maria Fox, Emma Marino) Project Staff : Michelle Vu, Kathleen Bagot, Joosup Kim, Sally Berger, Nancy Pompeani, Karen Biddiscombe, Chris Choi AuSCR Economic evaluation: Lauren Sheppard, Marj Moodie (Deakin University) Analysis Assistance: Leonid Churilov, Monique Kilkenny Funding: Victorian Government, Health and Hospitals Fund, Department of Health (Commonwealth) , Victorian Department of Health and Human Services, National Health and Medical Research Council

Thank you @VSTprogram @katiebagot www.vst.org.au