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In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

IMPORTANCE: Telestroke is increasingly used in hospital emergency departments, but there has been limited research on its impact on treatment and outcomes. OBJECTIVE: To describe differences in care patterns and outcomes among patients with acute ischemic stroke who present to hospitals with and without telestroke capacity. DESIGN, SETTING, AND PARTICIPANTS: Patients with acute ischemic stroke who first presented to hospitals with telestroke capacity were matched with patients who presented to control hospitals without telestroke capacity. All traditional Medicare beneficiaries with a primary diagnosis of acute ischemic stroke (approximately 2.5 million) who presented to a hospital between January 2008 and June 2017 were considered. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Hospitals included short-term acute care and critical access hospitals in the US without local stroke expertise. In 643 hospitals with telestroke capacity, there were 76 636 patients with stroke who were matched 1:1 to patients at similar hospitals without telestroke capacity. Data were analyzed in July 2020. MAIN OUTCOMES AND MEASURES: Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge. RESULTS: In the final sample of 153 272 patients, 88 386 (57.7%) were female, and the mean (SD) age was 78.8 (10.4) years. Patients cared for at telestroke hospitals had higher rates of reperfusion treatment compared with those cared for at control hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI, 0.54-1.03; P

Background: Telestroke is increasingly used by hospitals, but there has been limited research on its impact on treatment and outcomes. Methods: Using a 100% sample of traditional Medicare beneficiaries over a 10-year period, we compared the care patterns and outcomes of acute ischemic stroke admissions that first presented to hospitals with telestroke capacity to matched admissions in control hospitals without telestroke capacity. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Our primary outcomes were receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent in community living after discharge. Results: Over the period January 2008 through June 2017, there were 87,338 ischemic stroke admissions cared for at 643 telestroke hospitals of which 76,636 (88%) were matched to an admission at a control hospital. Compared to control admissions, admissions that started in telestroke hospitals had higher rates of reperfusion treatment (6.76% and 5.98%; difference 0.78, 95% CI 0.54 to 1.03, p Conclusions: Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and had lower 30-day mortality.

Importance Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear. Objective To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced. Design, Setting, and Participants This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary’s residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded. Exposures Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke. Main Outcomes and Measures Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality. Results The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, −35.4%). By 2017, this disparity was −26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, −0.02% to 0.6%]), respectively. Conclusions and Relevance In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

Introduction: Over the last decade substantial investments have been made in implementing stroke systems of care to improve access and quality of care. We sought to determine if these interventions have narrowed the rural-urban disparities in care over time for patients with acute stroke or transient ischemic attack (TIA). Methods: Descriptive observational study using data from all traditional Medicare beneficiaries in the United States from 2008-17 who presented to a hospital emergency department and were admitted either under observation stay or inpatient admission. Patients were classified as rural or urban based on home zip code. The main outcomes were rates of presentation to a certified stroke center, neurology consultation during admission, IV altepase, 90-day mortality, days living independently in the first 90 days post stroke, and 90-day spending. Results: We identified 3.31 million hospital stays for TIA and stroke in the study period. Rural and urban patients had similar age, race, gender, Medicaid status and presence of chronic conditions. In 2008, 24.4% and 60.4% of rural and urban patients respectively were cared for at a certified stroke center (disparity -36.1%). By 2017 this disparity had narrowed by 8.6% points (95% CI 6.6%,10.7%) (Fig). Between 2008 and 2017, the disparity in neurologist evaluation during admission narrowed by 7.4% (5.2%, 9.6%). However, there was no substantive change in disparity in alteplase use -0.1% (95% CI -0.5%,0.3%), mortality at 90 days 0.4% (95% CI 0.1%, 0.7%), or days living independently within 90 days -0.7 days (95% CI -1.1, 0.2). Spending in the first 90 days differentially increased among rural patients by $867 (95% CI 85, 1649). Conclusions: In the last decade, rural residents are more likely to receive care at a certified stroke center and receive neurologist consultation. However, disparities in outcomes are persistent, highlighting more work is needed to equitably extend stroke expertise to all Americans.

This study describes the growth of telestroke capacity in US hospitals and compares the characteristics of the hospitals with and without telestroke capacity.