Torabi Elham, Froehle Craig M, Lindsell Christopher J, Moomaw Charles J, Kanter Daniel, Kleindorfer Dawn, Adeoye Opeolu
Lindner College of Business, University of Cincinnati, Cincinnati, OH.
Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.
Acad Emerg Med. 2016 Jan;23(1):55-62. doi: 10.1111/acem.12839. Epub 2015 Dec 31.
The objective of this study was to evaluate operational policies that may improve the proportion of eligible stroke patients within a population who would receive intravenous recombinant tissue plasminogen activator (rt-PA) and minimize time to treatment in eligible patients.
In the context of a regional stroke team, the authors examined the effects of staff location and telemedicine deployment policies on the timeliness of thrombolytic treatment, and estimated the efficacy and cost-effectiveness of six different policies. A process map comprising the steps from recognition of stroke symptoms to intravenous administration of rt-PA was constructed using data from published literature combined with expert opinion. Six scenarios were investigated: telemedicine deployment (none, all, or outer-ring hospitals only) and staff location (center of region or anywhere in region). Physician locations were randomly generated based on their zip codes of residence and work. The outcomes of interest were onset-to-treatment (OTT) time, door-to-needle (DTN) time, and the proportion of patients treated within 3 hours. A Monte Carlo simulation of the stroke team care-delivery system was constructed based on a primary data set of 121 ischemic stroke patients who were potentially eligible for treatment with rt-PA.
With the physician located randomly in the region, deploying telemedicine at all hospitals in the region (compared with partial or no telemedicine) would result in the highest rates of treatment within 3 hours (80% vs. 75% vs. 70%) and the shortest OTT (148 vs. 164 vs. 176 minutes) and DTN (45 vs. 61 vs. 73 minutes) times. However, locating the on-call physician centrally coupled with partial telemedicine deployment (five of the 17 hospitals) would be most cost-effective with comparable eligibility and treatment times.
Given the potential societal benefits, continued efforts to deploy telemedicine appear warranted. Aligning the incentives between those who would have to fund the up-front technology investments and those who will benefit over time from reduced ongoing health care expenses will be necessary to fully realize the benefits of telemedicine for stroke care.
本研究的目的是评估可能提高符合条件的中风患者在人群中接受静脉注射重组组织型纤溶酶原激活剂（rt-PA）比例并缩短符合条件患者治疗时间的运营政策。
在区域中风团队的背景下，作者研究了工作人员位置和远程医疗部署政策对溶栓治疗及时性的影响，并估计了六种不同政策的疗效和成本效益。利用已发表文献的数据并结合专家意见，构建了一个包含从中风症状识别到静脉注射rt-PA各个步骤的流程图。研究了六种情况：远程医疗部署（无、全部或仅外圈医院）和工作人员位置（区域中心或区域内任何地方）。医生的位置根据他们的居住和工作邮政编码随机生成。感兴趣的结果是发病到治疗（OTT）时间、门到针（DTN）时间以及在3小时内接受治疗的患者比例。基于121例可能符合rt-PA治疗条件的缺血性中风患者的主要数据集，构建了中风团队护理提供系统的蒙特卡罗模拟。
当医生随机分布在该区域时，在该区域的所有医院部署远程医疗（与部分或不部署远程医疗相比）将导致3小时内的最高治疗率（80%对75%对70%）以及最短的OTT（148分钟对164分钟对176分钟）和DTN（45分钟对61分钟对73分钟）时间。然而，将值班医生集中安排并结合部分远程医疗部署（17家医院中的5家）在具有相当的符合条件率和治疗时间的情况下将是最具成本效益的。
鉴于潜在的社会效益，继续努力部署远程医疗似乎是有必要的。为了充分实现远程医疗对中风护理的益处，有必要调整那些必须为前期技术投资提供资金的人和那些将随着时间推移从持续医疗费用降低中受益的人之间的激励措施。
