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How Teleneurologists Can Enhance Acute and Chronic Patient Care

Virtual consultations are reliable and not as daunting as they might appear.


 

HILTON HEAD, SC—When neurologists see patients remotely, the focus should be on the patient, not on the technology behind the virtual visit, according to one researcher.

Kenneth Gaines, MD

“One of the big mistakes that is made with telehealth is focusing on the technology and not on the clinical care delivery,” said Kenneth Gaines, MD, Professor of Neurology at Vanderbilt University in Nashville. “It is the clinical care delivery that ought to drive the technology. Too often it happens in reverse…. That is a recipe for an ineffective program.”

Broadly speaking, telemedicine is medicine practiced at a distance. Ideally, it uses technology to facilitate a clinical care paradigm that improves efficiency, care coordination, and outcomes and lowers costs, Dr. Gaines said. The public increasingly expects this type of care to be available, he said.

“Why would telehealth be useful in neurology? In part because we deal with acute and chronic disease, which is what stroke is, for example, but also other diseases like epilepsy,” Dr. Gaines said at Vanderbilt’s 41st Annual Contemporary Clinical Neurology Symposium. In addition, neurologic diseases are complex, and generalists’ training in them may be limited. Telehealth could allow neurologists to assist general practitioners and provide neurologic care to areas with few neurologists.

Opportunity in Neurology

Systematic reviews in disease states like diabetes, hyperlipidemia, and hypertension have found that telemedicine may benefit patients. A 2015 Cochrane review of data from randomized controlled trials of interactive telemedicine found with moderate certainty that telemedicine decreased LDL and blood pressure, compared with usual care. It found with high certainty that among patients with diabetes, those who received telemedicine had lower glycated hemoglobin levels at nine months, compared with controls. Evidence to assess the effects of telemedicine in neurology, however, was inadequate.

Nevertheless, studies indicate telemedicine’s promise in neurology. Beck et al conducted the Connect.Parkinson trial, which included 195 patients with Parkinson’s disease who were randomized to usual care or usual care plus four virtual visits via video conferencing with a remote specialist. The researchers found that telemedicine was feasible and equivalent to usual care with regard to its effects on patients’ quality of life. The virtual house calls saved patients a median of 88 minutes and 38 miles per visit. Mammen et al analyzed survey data from patients with Parkinson’s disease and physicians and found that they generally were satisfied with the telemedicine approach, but technical problems affected individual experiences. Physicians’ greatest source of dissatisfaction was performing a detailed motor examination remotely.

Samii et al reported the experience of one Veterans Administration medical center that found it feasible to conduct follow-up visits with patients with Parkinson’s disease via telemedicine. Although the video quality initially was not sufficient to score the motor Unified Parkinson’s Disease Rating Scale, a videoconferencing unit upgrade allowed physicians to assess those measures, with the exception of elements that require physical contact, such as rigidity and retropulsion.

A study by Kane et al found that telemedicine assessments of patients with multiple sclerosis could reliably determine Expanded Disability Status Scale scores. Scores related to cerebellar and brainstem functions, however, were less consistent with the scores of a hands-on examiner than were scores related to optic, bowel, bladder, and cerebral functions.

In neurology, most studies of telemedicine have focused on stroke, perhaps because of the complex and time-sensitive nature of the disease and a maldistribution of health care providers, Dr. Gaines said.

The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in Germany connected 12 community hospitals that had limited experience with stroke thrombolysis to two specialized stroke centers. In the first 22 months, patients treated at the community hospitals and at the stroke centers had equivalent rates of mortality and good functional outcomes that were similar to those in randomized trials, Schwab et al reported.

In the STRokE DOC trial, Meyer et al assessed whether telemedicine (ie, real-time, two-way audio and video communication and digital imaging interpretation) or telephone consultation was superior in acute stroke consultations. In all, 111 patients were randomized to telemedicine, and 111 were randomized to telephone consultation. Ninety-day functional outcomes and rates of intracerebral hemorrhage after treatment with thromblytics and mortality were equivalent between the groups. With telemedicine, neurologists were more likely to arrive at a correct treatment decision and less likely to violate trial protocols, Dr. Gaines said.

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