title: Monte Carlo Simulation Modeling of a Regional Stroke Team's Use of Telemedicine.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Lindner College of Business, University of Cincinnati, Cincinnati, OH.|Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.
authors.forename: Elham
authors.initials: E
authors.lastname: Torabi
authors.affiliation: Lindner College of Business, University of Cincinnati, Cincinnati, OH.|Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.|Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Craig M
authors.initials: CM
authors.lastname: Froehle
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Moomaw
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH.|University of Cincinnati Neuroscience Institute, Cincinnati, OH.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kanter
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH.|University of Cincinnati Neuroscience Institute, Cincinnati, OH.
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.|Department of Neurosurgery, University of Cincinnati, Cincinnati, OH.|University of Cincinnati Neuroscience Institute, Cincinnati, OH.
authors.forename: Opeolu
authors.initials: O
authors.lastname: Adeoye
mesh_terms: D002545:Brain Ischemia / Q000188:drug therapy; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D009010:Monte Carlo Method; D012041:Regional Medical Programs / Q000458:organization & administration*; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D017216:Telemedicine / Q000706:statistics & numerical data*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator