1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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).

10. 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

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

12. 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), )
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

13. 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

14. 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

15. 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

16. 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

17. Thank you
@VSTprogram
@katiebagot