Mobile Stroke Units Gaining Traction in the United States

VBCN - May 2015 Volume 2, No 1

A recent test-run of a mobile stroke unit (MSU) in Houston, TX, has shown preliminary success in the treatment of patients diagnosed with ischemic stroke. During an 8-week pilot of the MSU, the first of its kind in the United States, 8 of 13 patients who were diagnosed with stroke and treated with recombinant tissue-type plasminogen activator (rtPA) received the life-saving drug within 80 minutes of symptom onset. The rest received the drug between 81 and 270 minutes after onset (Rajan S, et al. JAMA Neurol. 2015;72:229-234; Parker SA, et al. Stroke. 2015;46:1384-1391).

Several of the team members who piloted the MSU are now conducting a randomized trial that will include an evaluation of the costs of implementing and maintaining the unit, as well as of the healthcare costs associated with the unit compared with those for standard emergency medical services (EMS). Meanwhile, officials at University of Colorado Health are reported to be preparing another of these vehicles for use later this year, and Cleveland Clinic is reported to be operating one as well.

“I am gratified to see how smoothly the MSU operation can work once it is up and running, and how fast and efficiently we can treat patients. I am optimistic that this strategy can be applied in any community in the United States to speed stroke treatment,” James Grotta, MD, Director of the Mobile Stroke Unit Consortium, told Value-Based Care in Neurology. “I am curious to know exactly how much better recovery patients will make with such earlier treatment, and [am] realistic that whatever improved outcomes occur must be balanced against the costs.”

Dr Grotta, who is the principal investigator of the project and also Director of Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann–Texas Medical Center, has been working on the project for more than 2 years, dedicating 80% of his time to it since February 2014. He helped to secure funding for the project and oversee the purchase and equipping of the vehicle (including a CereTom computed tomography scanner and advanced life support supplies) as well as communication with Houston’s EMS department and training, staffing, and scheduling.

The MSU began operation on May 14, 2014, and underwent an 8-week pilot to test all aspects of the system. During that 2-month period, the MSU team was dispatched 130 times. In 106 cases, the team either did not go to the destination or assessed the patients and determined they did not qualify for the study; that is, they did not have symptom onset within the previous 4.5 hours and did not meet published criteria for rtPA treatment pending computed tomography scan and laboratory testing.

Of the remaining 24 patients who met criteria for enrollment, 11 were not treated for various reasons: an intracerebral hemorrhage lowered their blood pressure acutely (4 patients); they experienced seizures (3 patients); their symptoms improved and obviated the need for rtPA (2 patients); a subhematoma developed (1 patient); or the time of symptom onset was undermined (1 patient). Among the remaining 13 patients who were administered rtPA, 4 (31%) were given the drug within 60 minutes of symptom onset, another 4 (31%) at 61 to 80 minutes from onset, and 5 (38%) at 81 to 270 minutes from symptom onset. The team also successfully attempted remote telemedicine assessment of the patients.

The total cost of equipment and supplies was $633,300 for the first year of the MSU and is projected to be $79,000 annually after that. This excludes the cost of rtPA, which Dr Grotta and his colleagues documented in their paper as being $7816 per 100-mg vial. The team is conducting the Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services (BEST-MSU) study, and began enrolling patients in August 2014.

“Formal cost analysis would have to balance these costs [for the first year] plus costs for staffing and maintenance against any reduction in the total hospital and long-term care costs to the healthcare system for each patient with an ischemic stroke treated on the MSU, estimated to average approximately $140,000 per patient in 1999 US dollars, undoubtedly much higher today,” wrote Dr Grotta and his colleagues in a paper published in JAMA Neurology (Rajan S, et al. JAMA Neurol. 2015;
72:229-234).

They also posit that the vascular neurologist who currently rides with other staff on the MSU should be replaced by a remote vascular neurologist to reduce costs.

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