Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors.

BACKGROUND: Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. OBJECTIVES: The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. METHODS: We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. RESULTS: Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. CONCLUSIONS: These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing.

OBJECTIVE: To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN: This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING: Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS: Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS: Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS: Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Beyond acute stroke: Rate of stroke transfers to a tertiary centre following the implementation of a dedicated inpatient teleneurology network.

INTRODUCTION: This study evaluated the impact of establishing an inpatient teleneurology consultation service alongside an already established telestroke network on the stroke transfers to the hub. The study also aimed to assess the financial impact of establishing this network. METHODS: Prospectively collected data on all stroke patients evaluated through our telestroke and teleneurology networks between January 2008 and March 2018 were interrogated. For all spokes (eight sites) that had both teleneurology and telestroke services, we compared the rate of transfers to the hub before and after the establishment of the teleneurology network in August 2014. The cost reduction was estimated using the Medicare 5% standard analytic files. RESULTS: A total of 4296 stroke patients were evaluated during the study period. Of these, 2493 were seen before and 1803 were seen after the implementation of the teleneurology network at the included sites. Patients in the pre-teleneurology group were older (66.4 years (SD = 14.7 years) vs. 67.8 years (SD = 15.1 years); p = 0.002). Otherwise, there were no differences in baseline characteristics. Patients in the pre-teleneurology group were more likely to be transferred to the telestroke hub (29.4% vs. 20.2%; p < 0.001). The estimated mean cost reduction for each one minus the cost of transfer was estimated to be US$4997. DISCUSSION: The implementation of an inpatient teleneurology network was associated with a significant reduction in the transfer rate of stroke patients to hospitals with a higher level of care and could lead to a significant cost reduction.

Teleneurology Network to Improve Access to Neurologists for Patients in Rural Areas: A Real-World Experience.

Background: The need for neurologists has been steadily increasing over the past few years. The implementation of teleneurology networks could serve as a potential solution to this need. Methods: A retrospective review of the Medical University of South Carolina (MUSC) Teleneurology records for all consults performed between August 2014 and July 2018 was conducted. Collected data included number of consults, baseline characteristics, final diagnosis, and number of providers and hospitals over the study period. Results: A total of 4,542 Teleneurology consults were performed during the study period. The most common diagnosis was cerebrovascular disease, followed by seizure disorders. The number of consults per month increased throughout the study period from three in August 2014 to 257 in July 2018. The number of community hospitals covered has increased from 3 hospitals in August 2014 to 14 hospitals throughout the state of South Carolina in July 2018. Conclusion: Over 4 years, the MUSC teleneurology program has evolved into a robust partnership with 14 partner hospitals, and is now delivering more than 250 expert neurology consultations monthly to patients throughout the state of South Carolina.

Lessons Learned from Endovascular Coil Embolization of Pericallosal Artery Aneurysms and Adoption of Flow Diversion: A Retrospective Cohort Assessment of the Efficacy of Coiling and Flow Diversion.

BACKGROUND: The adoption of endovascular techniques for treatment of pericallosal artery aneurysms (PAAs) has been comparatively gradual due to anatomic and technological factors. We conducted a retrospective cohort study to evaluate the outcomes of PAA treatment with coiling and flow diversion at our institution. METHODS: This was a retrospective study of patients treated endovascularly for PAAs from December 2007 to January 2019. RESULTS: In total, 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72%, at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Angiographic follow-up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were coiled, 9 treated with flow diversion and 3 with "partial" flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was observed. Good clinical outcome (modified Rankin Scale 0-2) was seen in 79% of patients. CONCLUSIONS: Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation.