Abstract TP296: Telestroke Associated With Increased Levels of Acute Stroke Care

Introduction/Hypothesis: Telestroke may be used to augment hospitals’ acute stroke services. The Department of Veterans Affairs launched a National TeleStroke Program (NTSP) in September 2017 that provides emergency stroke consultative services at 30 VA hospitals as of August 2019. NTSP uses a virtual hub/spoke model, with transfer to community hospitals when required. We examined the hypothesis that NTSP sites would be overrepresented among VA medical centers increasing their level of acute stroke care between 2012 and 2019. Methods: All VA hospitals with an emergency department or urgent care center were required to submit their stroke policies in 2012 certifying the level of acute stroke care offered: VA primary stroke centers provide alteplase evaluation and treatment 24/7/365, limited hours stroke facilities provide alteplase evaluation and treatment typically during business hours, or supporting stroke facilities which transfer all stroke patients for acute care. Re-attestation was required in 2019, with an additional category of comprehensive stroke center added, reflecting availability of both alteplase and endovascular thrombectomy 24/7/365. All submitted documents were reviewed by a single stroke neurologist and the level of acute stroke services was tabulated. Results: Of the 115 VA hospitals submitting complete documents, 25 increased their level of acute stroke care, and only 2 decreased their level of acute stroke care between 2012 and 2019. Sixteen of 30 NTSP sites (53%) enhanced acute stroke care in 2019 vs. 2012, compared to 9 of 85 hospitals (11%) not using telestroke. The difference was highly significant (p < 0.0001, Chi-square test). Conclusions: In a large, national health care system less driven by financial incentives than most US medical care, adoption of telestroke services was successful in enhancing local VA hospital stroke care. This difference was especially apparent at smaller, rural VA hospitals with limited access to VA neurology services and (in some cases) non-VA care options.

Abstract TP237: Uneven Distribution of Stroke Patients and Stroke Centers

Background: Texas is a large state with high demographic and geographic diversity. We analyzed the distribution of high-risk patients and stroke care hospitals to determine how to optimally distribute resources to benefit the largest number of patients. Methods: Data on overall state demographics were based on 2013 estimates derived from 2010 US census data. The number of hospitals was provided by the Department of State Health Services (DSHS). Stroke patients were ascertained via cms.gov and Texas DSHS data. Stroke data were available from 233 of 254 counties. Hospital designation in Texas is based on state-based criteria, but largely follows the definitions used by the Joint Commission. Results: Texas has approximately 26.4 million people (43% white, 39% Hispanic, 12% black, and 6% other). There are almost 3.3 million Medicare beneficiaries, of whom 94,071 have had a stroke. Texas has 649 hospitals with 84,000 licensed beds. There are 135 stroke facilities in 49 counties; 205 counties have no designated stroke facilities. Stroke designated hospitals include 12 CSCs, 110 PSCs, and 13 ASRH. There are 79 Critical Access Hospitals (CAH) that provide varying degrees of stroke care but have diverse locations (see map). The majority of Stroke Centers are located in or around large urban areas. The number of stroke patients varied significantly by county, with as few as 11 and as many as 12,844 in some counties. Many counties with large Medicare populations have few or no stroke centers. Conclusions: The distribution of stroke patients and stroke facilities in Texas is often mismatched. Processes to better match stroke resources with high-risk populations might improve stroke systems of care and perhaps outcomes. Conversion of some CAHs to ASRHs might alleviate some of these disparities.

Abstract 2667: Comparative Effectiveness Analysis of Stroke Center Designations on Patient Outcomes

Background: Stroke designation has become increasingly important for administrators and physicians of stroke facilities in recent years. Designation (accreditation, recognition) as a stroke center implies to the community tangible evidence of quality, yet no study has assessed the comparative effectiveness of outcomes for designation in stroke. Methods: Using 2004 to 2009 for all patients treated for acute ischemic stroke across all 547 hospitals in Texas, we perform a comparative effectiveness analysis. Ischemic strokes include only ICD-9 codes 433-436. De-identified data were obtained from the Texas Health Care Information Collection data files. Hospitals were categorized in three groups: 1) recognition from the American Heart Association Get With the Guidelines Stroke program; 2) accreditation from the Joint Commission as a Primary Stroke Center (PSC), or 3) non-accredited from either of these programs. We compared each of these three subgroups employing various tests for differences and logistic regressions for odds ratios at 95% CI. Outcome measures assessed include mortality rate, average length of stay (ALOS), treatment costs, and use of thrombolysis. We adjusted mortality rates and lytics utilization based on risk mortality, illness severity, and patient age to control for mix and acuity. We calculated lytics rates dividing total cases where lytics were utilized by total ischemic strokes. We adjusted hospital reported charges using a standard cost-charge ratio. Results: 41 hospitals (7.5%) are recognized by the GWTG Gold or Silver levels, and 77 (14%) were recognized as a Primary Stroke Center. The remainder had neither designation. Of the 275,163 total strokes, 86% were ischemic. ALOS for all patients was 5.3 days, and average hospital costs were $36,529. Average mortality rate was 3.5% and mean lytics utilization was 1.6% across all cases. KW median test confirms that PSC hospitals had significantly lower ALOS compared to the non-accredited group (5.1 days vs. 5.5) and lower costs ($34,428 vs. $38,952). Logistics regressions showed significantly higher lytics rate (OR=3.3) as well as marginally higher mortality rates (OR=1.1). The GWTG subgroup had similar statistically significant results with ALOS (5.1) and costs ($34,792) both being significantly less than the non-accredited group. The odds ratio for lytics usage was exactly twice that of the non-accredited group. Mortality rates however were not significantly different between the two groups. Conclusion: Accreditation or designation of stroke facilities is associated with more efficient practice of care and improved processes (shorter stays, lower costs, and improved lytics use). Mortality rate however was marginally higher in one of the two accredited subgroups, but not in the other. Results suggest expansion of strengthening and expansion of designation programs.