Association of specialist involvement and quality of care for Parkinson's disease

Comprehensive real time remote monitoring for Parkinson's disease using Quantitative DigitoGraphy

People with Parkinson's disease (PWP) face critical challenges, including lack of access to neurological care, inadequate measurement and communication of motor symptoms, and suboptimal medication management and compliance. We have developed QDG-Care: a comprehensive connected care platform for Parkinson's disease (PD) that delivers validated, quantitative metrics of all motor signs in PD in real time, monitors the effects of adjusting therapy and medication adherence and is accessible in the electronic health record. In this article, we describe the design and engineering of all components of QDG-Care, including the development and utility of the QDG Mobility and Tremor Severity Scores. We present the preliminary results and insights from an at-home trial using QDG-Care. QDG technology has enormous potential to improve access to, equity of, and quality of care for PWP, and improve compliance with complex time-critical medication regimens. It will enable rapid "Go-NoGo" decisions for new therapeutics by providing high-resolution data that require fewer participants at lower cost and allow more diverse recruitment.

Post-Traumatic Stress Disorder and Risk of Parkinson's Disease in a Veteran Cohort

 Post-traumatic stress disorder (PTSD) may be a risk factor for Parkinson's disease (PD). We examined the relation between PTSD and PD in a cohort of 158,122 Veterans who had any Veterans Health Administration (VHA) or Medicare health care utilization between 10/1/1999- 2/17/2021. Using a nested case-control design we matched 10 controls to each Veteran with PD by sex, race, and rank. In conditional logistic regression models adjusted for camp and smoking, a PTSD diagnosis was significantly associated with PD (OR = 1.35; p = 0.0002); odds were higher if PTSD was coded before PD (OR = 1.53, p < 0.0001). PTSD may be a risk factor for PD.

Tools and criteria to select patients with advanced Parkinson's disease for device-aided therapies: a narrative review

This article provides an overview of the various screening and selection tools which have been developed over the past 25 years to identify patients with Parkinson's disease (PD) possibly eligible for device-aided therapies (DATs). For the available screening tools, we describe the target therapies (subtypes of DAT), development methods, validation data, and their use in clinical practice. In addition, the historical background and potential utility of these screening tools are discussed. The challenges in developing and validating these tools are also addressed, taking into account the differences in population, the local health care organization, and resource availability.

Advanced‐Stage Parkinson's disease: From Identification to Characterization Using a Nationwide Database

Background

As Parkinson's disease (PD) progresses, response to oral medications decreases and motor complications appear. Timely intervention has been demonstrated as effective in reducing symptoms. However, current instruments for the identification of these patients are often complicated and inadequate. It has been suggested that anti-PD intensified therapy (IT) can serve as a proxy for increased burden of disease.

Objective

To explore whether IT aligns with events reflecting advanced PD (APD) burden.

Methods

This was a retrospective analysis of PD beneficiaries in the second-largest healthcare provider in Israel. Patients with PD diagnosed between January 2000 and June 2018 and treated with levodopa (l-dopa) ≥5 times/day and/or ≥1000 mg l-dopa equivalent daily dose were defined as the IT cohort (n = 2037). Treated patients with PD not fulfilling this criterion were defined as the nonintensified therapy (NIT) cohort (n = 3402). Point prevalence and 5- and 10-year cumulative incidence of IT were assessed. Baseline demographic and comorbidities, 1-year healthcare resource use, health costs, and time to clinical events were assessed and compared between cohorts.

Results

IT was associated with significantly (P < 0.05) higher healthcare resource use compared with NIT. In turn, IT patients incurred higher healthcare costs (P < 0.001) and were at greater risk for mortality, hospitalization, disability, and device-aided therapy use (P < 0.001, for all comparisons).

Conclusions

Treatment intensity can serve as an objective and robust indicator of more APD. This readily extractable marker can be easily integrated into electronic medical record alerts to actively target more advanced patients and to guide risk-appropriate care.

Improving Access to Tertiary Movement Disorders Subspecialty Care: A Team Model Born From the COVID-19 Crisis

Patient demand continues to outpace growth of the neurology workforce, especially in its subspecialties such as movement disorders. Various strategies have been deployed to address this. The COVID-19 pandemic accentuated the mismatch by propelling telemedicine and access demands to the forefront. Previously, we reported improving general neurology access using a physician-advanced practice provider (APP) team model. Here, we share our experiences of piloting a similar model in subspecialty care (movement disorders) between September 1 and December 17, 2020. Before the pilot, the wait time to be seen by movement disorders subspecialists exceeded four months. Our data show marked improvement in new patient access (23.8% improvement as well as 214% increase in number of new patients seen) with excellent patient acceptance. Our approach and the lessons learned may be useful to address access for other neurology subspecialties.

Implementation fidelity of a nurse-led RCT-tested complex intervention, care coordination for health promotion and activities in Parkinson's disease (CHAPS) in meeting challenges in care management

BACKGROUND

Parkinson's disease (PD) complexity poses challenges for individuals with Parkinson's, providers, and researchers. A recent multisite randomized trial of a proactive, telephone-based, nurse-led care management intervention - Care Coordination for Health Promotion and Activities in Parkinson's Disease (CHAPS) - demonstrated improved PD care quality. Implementation details and supportive stakeholder feedback were subsequently published. To inform decisions on dissemination, CHAPS Model components require evaluations of their fidelity to the Chronic Care Model and to their implementation. Additionally, assessment is needed on whether CHAPS addresses care challenges cited in recent literature.

METHODS

These analyses are based on data from a subset of 140 intervention arm participants and other CHAPS data. To examine CHAPS Model fidelity, we identified CHAPS components corresponding to the Chronic Care Model's six essential elements. To assess implementation fidelity of these components, we examined data corresponding to Hasson's modified implementation fidelity framework. Finally, we identified challenges cited in current Parkinson's care management literature, grouped these into themes using open card sorting techniques, and examined CHAPS data for evidence that CHAPS met these challenges.

RESULTS

All Chronic Care Model essential elements were addressed by 17 CHAPS components, thus achieving CHAPS Model fidelity. CHAPS implementation fidelity was demonstrated by adherence to content, frequency, and duration with partial fidelity to telephone encounter frequency. We identified potential fidelity moderators for all six of Hasson's moderator types. Through card sorting, four Parkinson's care management challenge themes emerged: unmet needs and suggestions for providers (by patient and/or care partner), patient characteristics needing consideration, and standardizing models for Parkinson's care management. CHAPS activities and stakeholder perceptions addressed all these themes.

CONCLUSIONS

CHAPS, a supportive nurse-led proactive Parkinson's care management program, improved care quality and is designed to be reproducible and supportive to clinicians. Findings indicated CHAPS Model fidelity occurred to the Chronic Care Model and fidelity to implementation of the CHAPS components was demonstrated. Current Parkinson's care management challenges were met through CHAPS activities. Thus, dissemination of CHAPS merits consideration by those responsible for implementing changes in clinical practice and reaching people in need.

TRIAL REGISTRATION

ClinicalTrials.gov as NCT01532986 , registered on January 13, 2012.

Difference in rural and urban Medicare prescription pattern for Parkinson’s disease in Hawai‘i

Background

Medical management of Parkinson’s Disease (PD) is becoming complex. Increasing evidence suggests that patients have better outcomes when they are managed by neurologists. However, access to neurologists can be limited in rural areas. Analysis of prescription pattern can provide insight into access gap rural patients face.

Methods

This retrospective observational study used National Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from 2013 to 2018. Query was made for levodopa, dopamine agonists and other antiparkinsonian medications. The data elements obtained included drug name, number of prescribers, prescriber specialty, number of claims, number of standardized 30-day Part D prescriptions, and number of Medicare beneficiaries in the state of Hawai‘i. Individual prescribing providers were categorized as urban or rural based on their cities of practice. Prescription patterns of urban and rural providers in Hawai‘i as well as difference in provider specialty were compared, using standardized 30-day prescriptions as the primary measure of utilization.

Results

Practice patterns differed between rural and urban areas. In rural Hawai‘i, Rytary, Rotigoitne and selegiline were rarely prescribed. Levodopa percentage was higher in urban Hawai‘i. In urban Hawai‘i, 74.4% of the prescriptions were provided by movement disorders and general neurologists. In rural Hawai'i, 25.1% of the prescriptions were written by neurologists and 74.9% by general practitioners.

Conclusions

In the state of Hawai‘i, there is an urban–rural access gap to neurologists as evidenced by Medicare prescription pattern. Further study is needed to understand the reasons for rural–urban differences in prescription patterns and their impact on outcomes.

Adopting a multidisciplinary telemedicine intervention for fall prevention in Parkinson's disease. Protocol for a longitudinal, randomized clinical trial

Background

Approximately 40–70% of people with Parkinson’s disease (PD) fall each year, causing decreased activity levels and quality of life. Current fall-prevention strategies include the use of pharmacological and non-pharmacological therapies. To increase the accessibility of this vulnerable population, we developed a multidisciplinary telemedicine program using an Information and Communication Technology (ICT) platform. We hypothesized that the risk for falling in PD would decrease among participants receiving a multidisciplinary telemedicine intervention program added to standard office-based neurological care.

Objective

To determine the feasibility and cost-effectiveness of a multidisciplinary telemedicine intervention to decrease the incidence of falls in patients with PD.

Methods

Ongoing, longitudinal, randomized, single-blinded, case-control, clinical trial. We will include 76 non-demented patients with idiopathic PD with a high risk of falling and limited access to multidisciplinary care. The intervention group (n = 38) will receive multidisciplinary remote care in addition to standard medical care, and the control group (n = 38) standard medical care only. Nutrition, sarcopenia and frailty status, motor, non-motor symptoms, health-related quality of life, caregiver burden, falls, balance and gait disturbances, direct and non-medical costs will be assessed using validated rating scales.

Results

This study will provide a cost-effectiveness assessment of multidisciplinary telemedicine intervention for fall reduction in PD, in addition to standard neurological medical care.

Conclusion

In this challenging initiative, we will determine whether a multidisciplinary telemedicine intervention program can reduce falls, as an alternative intervention option for PD patients with restricted access to multidisciplinary care.

Trial registration

ClinicalTrials.gov Identifier: NCT04694443.

What People with Parkinson's Disease Want

Parkinson’s disease is an incurable, progressive neurodegenerative disease. This condition is complicated by the varying symptoms in individuals who differ in age of onset, symptoms, progression of disease, response to treatment and prognosis. In this paper, we focus on quality of life achieved through a combination of comprehensive health care, continuous support, and self care. Determining what people with Parkinson’s disease want is like assembling multiple puzzles simultaneously. While we surmise that patient centered care, support programs, access to comprehensive health care, and relevant symptom control are pieces of this puzzle, more longitudinal studies— which are observational in nature and correlate the impact of symptoms with patients’ reported needs— are necessary.

Telemedicine in Neurology: A Scoping Review of Key Outcomes in Movement Disorders

Background: Telemedicine for neurological care has been researched and practiced in various ways over the past three decades, but the recent COVID-19 pandemic has rapidly expanded its use and highlighted the need for a synthesis of the existing literature. We aimed to review the methodology and outcomes of previous studies that have evaluated the use of telemedicine in movement disorders. Methods: This scoping review was performed by searching PubMed, Ovid MEDLINE, and CINAHL databases from 1946 to November 2020. Studies that assessed the application of telemedicine for delivering care to patients with a movement disorder were included. We reported the aims and employed methodologies and categorized the outcomes from each study. Results: The search retrieved 228 articles, and 41 studies met the criteria for inclusion in the review. The majority of telemedicine studies were case series or randomized controlled pilot trials, investigating feasibility and acceptability in Parkinson's disease. Even with heterogeneity among outcome measures, they can be categorized into themes, such as feasibility, satisfaction, and efficacy. Conclusions: Telemedicine use has grown rapidly, due to the demands of providing care during a global pandemic. This application of telemedicine has been considered a promising way to expand care in Neurology, although research evaluating the dissemination of its use is dilatory. This review highlights the number of studies that have found telemedicine to be an acceptable and feasible way to deliver care for movement disorders. Further research is needed to expand on harmonization of outcomes, reach, adoption, and long-term use of telemedicine.

Response to Telemedicine Visits From Patients With Parkinsonism During the COVID-19 Pandemic on Postvisit Surveys

Parkinson's disease and parkinsonism are common chronic neurodegenerative disorders that tend to affect older adults and cause physical and sometimes cognitive limitations. Given that these limitations could impact successful telemedicine use, we aimed to investigate the experiences of patients with parkinsonism using telemedicine during the COVID-19 pandemic. A 19-item survey was emailed to patients with parkinsonism following telemedicine visits at a single US tertiary care parkinsonism specialty clinic. Seventy-four individuals responded, out of 270 invitations sent. Almost two-thirds (61.6%) of the respondents were comfortable with using technology in general, and almost all were very satisfied with their telemedicine experience. The most commonly reported benefits included cost and travel savings, ease of access to a specialist, and time savings. Issues with technology and previsit instructions were the most commonly identified challenges (28%). Urgent implementation, due to the pandemic, of telemedicine care for patients with parkinsonism was feasible and well received. The challenges most commonly reported by patients could be potentially alleviated by better education and support.

Lack of Accredited Clinical Training in Movement Disorders in Europe, Egypt, and Tunisia

BACKGROUND

Little information is available on the official postgraduate and subspecialty training programs in movement disorders (MD) in Europe and North Africa.

OBJECTIVE

To survey the accessible MD clinical training in these regions.

METHODS

We designed a survey on clinical training in MD in different medical fields, at postgraduate and specialized levels. We assessed the characteristics of the participants and the facilities for MD care in their respective countries. We examined whether there are structured, or even accredited postgraduate, or subspecialty MD training programs in neurology, neurosurgery, internal medicine, geriatrics, neuroradiology, neuropediatrics, and general practice. Participants also shared their suggestions and needs.

RESULTS

The survey was completed in 31/49 countries. Structured postgraduate MD programs in neurology exist in 20 countries; structured neurology subspecialty training exists in 14 countries and is being developed in two additional countries. Certified neurology subspecialty training was reported to exist in 7 countries. Recommended reading lists, printed books, and other materials are the most popular educational tools, while courses, lectures, webinars, and case presentations are the most popular learning formats. Mandatory activities and skills to be certified were not defined in 15/31 countries. Most participants expressed their need for a mandatory postgraduate MD program and for certified MD sub-specialization programs in neurology.

CONCLUSION

Certified postgraduate and subspecialty training exists only in a minority of European countries and was not found in the surveyed Egypt and Tunisia. MD training should be improved in many countries.

Spinal cord stimulation for chronic intractable trunk or limb pain: study protocol for a Chinese multicenter randomized withdrawal trial (CITRIP study)

Background

Although effective results of many studies support the use of spinal cord stimulation in chronic pain patients, no randomized controlled trial has been undertaken in China to date. CITRIP is a multicenter, prospective, randomized, withdrawal study designed to evaluate the clinical effectiveness and safety of spinal cord stimulation plus remote programming management in patients with intractable trunk or limb pain.

Method

Participants will be recruited in approximately 10 centers across China. Eligible participants with intractable trunk or limb and an average visual analog scale (VAS) score ≥ 5 will undergo a spinal cord stimulation test. Participants with VAS score reduction ≥ 50% could move forward to receive implantation of an implanted pulse generator. In the withdrawal period at 3-month follow-up visit, participants randomized to the experimental group (EG) will undergo continuous stimulation while ceasing the stimulation in the control group (CG). The outcome assessment will occur at baseline and at 1, 3 (pre- and post-randomization), and 6 months. The primary outcome is the difference of maximal VAS score between EG and CG in the withdrawal period compared with baseline before the withdrawal period. Additional outcomes include VAS score change at 1-, 3-, and 6-month follow-ups; responder rate (VAS score improving by 50%); achievement rate of a desirable pain state (VAS score ≤ 4); awake times during sleep; Beck Depression Inventory for depression evaluation; short-form 36 for quality of life evaluation; drug usage; and satisfaction rating of the device. Adverse events will be collected. The primary analysis will follow the intention-to-treat principle.

Discussion

The CITRIP study seeks to evaluate the effectiveness and safety of a randomized withdrawal trial of spinal cord stimulation for patients with intractable trunk or limb pain.

Trial registration

ClinicalTrials.gov NCT03858790. Registered on March 1, 2019, retrospectively registered

Effects of β2-Adrenergic Agonists on Risk of Parkinson's Disease in COPD: A Population-Based Study

INTRODUCTION

Multiple studies have investigated the role of β₂ -adrenoreceptor agonists on the risk of Parkinson's disease (PD). However, whether β₂ -agonist use is associated with the risk of PD in patients with chronic obstructive pulmonary disease (COPD) has not been examined to date.

OBJECTIVES

To examine the association between use of β₂ -agonist and the risk of PD in patients with COPD.

METHODS

A case-control study nested within a cohort of patients with COPD using the British Columbia health administrative databases from 1997 to 2015 was performed. Among a cohort of patients with COPD, all cases of PD were identified, and matched each case to up to five controls by age and calendar time. The use of β₂ -agonists was assessed between the third and fourth year preceding the date of PD diagnosis, followed by additional two years of grace period (between the first and second year preceding PD incidence) to control for PD latency. The use of β₂ -agonists was categorized into three levels: regular use (≥ 1 dispensation for every 6 months), irregular use (dispensation in one to three 6-month periods), and no use. A conditional logistic regression model was used to estimate the rate ratio of PD according to β2-agonist use, rigorously controlling for confounding variables.

RESULTS

Among 242,218 COPD patients, 732 PD cases and 3660 controls were identified. Use of β₂ -agonists did not significantly affect the subsequent risk of PD (vs no use, adjusted rate ratios: regular use, 1.14 [95% CI: 0.93, 1.40, p=0.21], irregular use, 1.15 [95% CI: 0.92, 1.45, p=0.22]). Results remained consistent with competing risk sensitivity analysis.

CONCLUSION

Use of β₂ -agonists does not appear to affect the risk of PD in a real-world COPD population.

The Promise of Telemedicine for Movement Disorders: an Interdisciplinary Approach

PURPOSE OF REVIEW

Advances in technology have expanded telemedicine opportunities covering medical practice, research, and education. This is of particular importance in movement disorders (MDs), where the combination of disease progression, mobility limitations, and the sparse distribution of MD specialists increase the difficulty to access. In this review, we discuss the prospects, challenges, and strategies for telemedicine in MDs.

RECENT FINDINGS

Telemedicine for MDs has been mainly evaluated in Parkinson's disease (PD) and compared to in-office care is cost-effective with similar clinical care, despite the barriers to engagement. However, particular groups including pediatric patients, rare MDs, and the use of telemedicine in underserved areas need further research. Interdisciplinary telemedicine and tele-education for MDs are feasible, provide similar care, and reduce travel costs and travel time compared to in-person visits. These benefits have been mainly demonstrated for PD but serve as a model for further validation in other movement disorders.

Teleneurology and mobile technologies: the future of neurological care

Neurological disorders are the leading cause of global disability. However, for most people around the world, current neurological care is poor. In low-income countries, most individuals lack access to proper neurological care, and in high-income countries, distance and disability limit access. With the global proliferation of smartphones, teleneurology - the use of technology to provide neurological care and education remotely - has the potential to improve and increase access to care for billions of people. Telestroke has already fulfilled this promise, but teleneurology applications for chronic conditions are still in their infancy. Similarly, few studies have explored the capabilities of mobile technologies such as smartphones and wearable sensors, which can guide care by providing objective, frequent, real-world assessments of patients. In low-income settings, teleneurology can increase the capacity of local care systems through professional development, diagnostic support and consultative services. In high-income settings, teleneurology is likely to promote the expansion and migration of neurological care away from institutions, incorporate systems of asynchronous communication (such as e-mail), integrate clinicians with diverse skill sets and reach new populations. Inertia, outdated policies and social barriers - especially the digital divide - will slow this progress at considerable cost. However, a future increasingly will be possible in which neurological care can be accessed by anyone, anywhere. Here, we examine the emerging evidence regarding the benefits of teleneurology for chronic conditions, its role and risks in low-income countries and the promise of mobile technologies to measure disease status and deliver care. We conclude by discussing the future trends, barriers and timing for the adoption of teleneurology.

National randomized controlled trial of virtual house calls for Parkinson disease

OBJECTIVE

To determine whether providing remote neurologic care into the homes of people with Parkinson disease (PD) is feasible, beneficial, and valuable.

METHODS

In a 1-year randomized controlled trial, we compared usual care to usual care supplemented by 4 virtual visits via video conferencing from a remote specialist into patients' homes. Primary outcome measures were feasibility, as measured by the proportion who completed at least one virtual visit and the proportion of virtual visits completed on time; and efficacy, as measured by the change in the Parkinson's Disease Questionnaire-39, a quality of life scale. Secondary outcomes included quality of care, caregiver burden, and time and travel savings.

RESULTS

A total of 927 individuals indicated interest, 210 were enrolled, and 195 were randomized. Participants had recently seen a specialist (73%) and were largely college-educated (73%) and white (96%). Ninety-five (98% of the intervention group) completed at least one virtual visit, and 91% of 388 virtual visits were completed. Quality of life did not improve in those receiving virtual house calls (0.3 points worse on a 100-point scale; 95% confidence interval [CI] -2.0 to 2.7 points; p = 0.78) nor did quality of care or caregiver burden. Each virtual house call saved patients a median of 88 minutes (95% CI 70-120; p < 0.0001) and 38 miles per visit (95% CI 36-56; p < 0.0001).

CONCLUSIONS

Providing remote neurologic care directly into the homes of people with PD was feasible and was neither more nor less efficacious than usual in-person care. Virtual house calls generated great interest and provided substantial convenience.

CLINICALTRIALSGOV IDENTIFIER

NCT02038959.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients with PD, virtual house calls from a neurologist are feasible and do not significantly change quality of life compared to in-person visits. The study is rated Class III because it was not possible to mask patients to visit type.

Patient and Physician Perceptions of Virtual Visits for Parkinson's Disease: A Qualitative Study

Background and Introduction: Delivering care through telemedicine directly into the patient's home is increasingly feasible, valuable, and beneficial. However, qualitative data on how patients' and physicians' perceive these virtual house calls are lacking. We conducted a qualitative analysis of perceptions of these visits for Parkinson's disease to (1) determine how patients and physicians perceive virtual visits and (2) identify components contributing to positive and negative perceptions.

MATERIALS AND METHODS

Qualitative survey data were collected from patients and physicians during a 12-month randomized controlled trial of virtual house calls for Parkinson's disease. Data from 149 cases were analyzed using case-based qualitative content analysis and quantitative sentiment analysis techniques.

RESULTS

Positive and negative perceptions of virtual visits were driven by three themes: (1) personal benefits of the virtual visit, (2) perceived quality of care, and (3) perceived quality of interpersonal engagement. In general, participants who identified greater personal benefit, high quality of care, and good interpersonal engagement perceived visits positively. Technical problems with the software were commonly mentioned. The sentiment analysis for patients was strongly favorable (+2.5) and moderately favorable for physicians (+0.8). Physician scores were lowest (-0.3) for the ability to perform a detailed motor examination remotely.

DISCUSSION

Patients and providers generally view telemedicine favorably, but individual experiences are dependent on technical issues.

CONCLUSIONS

Satisfaction with and effectiveness of remote care will likely increase as common technical problems are resolved.

Prevalence and Correlates of Anti-Parkinson Drug Use in a Nationally Representative Sample

BACKGROUND

Although numerous prescription drugs are available to treat Parkinson's disease (PD), little is known about national use in clinical practice and which factors may influence variability in care. The objectives of this study were to describe the prevalence of anti-Parkinson drug use among Medicare beneficiaries with PD and to identify demographic and clinical factors associated with drug use.

METHODS

This retrospective study was based on a random sample of annual 5% Medicare Part A and B claims linked with Medicare Part D drug files from 2007 through 2010. The study sample included fee-for-service Medicare beneficiaries with continuous stand-alone Part D enrollment who had been diagnosed with PD in the given year. First, any PD drug use and drug use by class (levodopa, dopamine agonist, anticholinerigc, monoamine oxidase B inhibitors, catechol-O-methyltransferase inhibitors, and amantadine) were described. Using generalized estimating equation regressions, patient and provider characteristics associated with anti-Parkinson drug use and choice were examined.

RESULTS

Over 81% of patients with PD were treated with anti-Parkinson drugs, and this proportion was stable over the 4 years of the study. The majority were treated with levodopa (90%); followed by dopamine agonists (29-31%); then monoamine oxidase B inhibitors, anticholinergics, amantadine, and catechol-O-methyltransferase inhibitors (all between 5% and 11%). Holding all else equal, patients who were not seen by a neurologist (odds ratio, 0.41; 95% confidence interval, 0.38-0.44; P < 0.001) and African-American patients (odds ratio, 0.80; 95% confidence interval, 0.69-0.93; P = 0.003) were significantly less likely to be treated.

CONCLUSIONS

Among a national sample of Medicare beneficiaries with PD, the majority received anti-Parkinson drugs. However, there was relative under-treatment of African-Americans and patients who were not seen by a neurologist for care.

Models of Care Delivery for Patients With Parkinson Disease Living in Rural Areas

The elderly who suffer from chronic conditions have an increasingly difficult time accessing health care in rural areas compared with their healthy counterparts who seek and utilize less specialty care. Parkinson disease affects approximately 0.3% to 5% of the elderly population. However, a large portion of that population has difficulty accessing health care. The purpose of this study was to obtain an understanding of the access to care issues for patients with Parkinson disease and review solutions to aid their provision of care. A review of the literature found several models of care available to improve access to care issues for patients with Parkinson disease.

Telehealth for patients with Parkinson's disease: delivering efficient and sustainable long-term care

OBJECTIVES

We set out to demonstrate the benefits of providing long-term care via telehealth for patients with Parkinson's disease living in continuous care facilities.

METHODS

A cohort of 16 patients with Parkinson's disease residing at one of 2 locations of a multi-facility continuous care retirement organization were seen virtually in follow-up over a 3-year period by Telehealth Services at a large, academic, tertiary care hospital in southeastern Pennsylvania. The data collected during that period, studied retrospectively, included demographic information, number of telehealth visits, and UPDRS scores obtained at each visit. Satisfaction and potential cost savings were also reviewed.

RESULTS

UPDRS scores declined over the period of observation, from a range of 18-60 at study start to 28-72 at study end. Actual cost savings are difficult to define; however, the cost per telehealth visit at $117.30 was often lower than the facility's average cost for transporting patients to a visit in the neurologist's office. Patients, families, subspecialists, and the nursing staff expressed uniformly high satisfaction with telehealth.

CONCLUSION

This model for providing care proved to be sustainable and efficient, and promoted collaboration among the providers at the long-term care facility and those at the remote site. These benefits may be applicable to patients with degenerative disorders in similar settings.

High patient satisfaction with telehealth in Parkinson disease: A randomized controlled study

BACKGROUND

Parkinson disease (PD) is a complex neurodegenerative disorder that benefits from specialty care. Telehealth is an innovative resource that can enhance access to this care within a patient-centered framework. Research suggests that telehealth can lead to increased patient satisfaction, equal or better clinical outcomes, and cost savings, but these outcomes have not been well-studied in PD.

METHODS

We conducted a dual active-arm 12-month randomized controlled trial to assess patient satisfaction, clinical outcomes, travel burden, and health care utilization in PD using video telehealth for follow-up care with specialty providers. Telehealth visits took place either at a facility nearer to the patient (satellite clinic arm) or in the patient's home (home arm). Each control group received usual in-person care. Patient satisfaction, assessed by quantitative questionnaires, was the primary outcome.

RESULTS

Eighty-six men were enrolled (home arm: 18 active, 18 control; satellite clinic arm: 26 active, 24 control) with a mean age of 73 years (range 42-87). There were no differences in baseline characteristics between the active group and the controls in each arm (p > 0.05). A significant difference in overall patient satisfaction was not found; however, high levels of patient satisfaction were found in all groups. Greater satisfaction for the telehealth modality was found in assessments of convenience and accessibility/distance. Clinical outcomes were similar between groups, travel burden was reduced using telehealth, and health care utilization was largely similar in both groups.

CONCLUSIONS

As the need for PD subspecialty care increases, innovative patient-centered solutions to overcoming barriers to access, such as video telehealth, will be invaluable to patients and may provide high patient satisfaction.

Association of adherence to epilepsy quality standards with seizure control

OBJECTIVE

We assessed the relationship between adherence to epilepsy quality measures (EQM) and seizure control over 2-3 years in a retrospective cohort study.

METHODS

6150 patients were identified at two large academic medical centers with a primary or secondary diagnosis of epilepsy, were 18-85 years old and seen in outpatient general neurology or epilepsy units between June 2011 and May 2014. Patients were included if: their initial visit was between June 2011 and June 2012, treatment was with ≥1 anti-seizure drug, there was ≥1 visit per year during the timeframe, and seizure frequency was documented at initial and final visits, yielding 162 patients/1055 visits from which socio-demographic, clinical and care quality data were abstracted. Quality care was assessed as (1) percent adherence to up to 8 eligible EQM, and (2) defect-free care (DFC: adherence to all eligible EQM). Seizure control (SC) was defined as ≥50% reduction in average seizures/month between initial and final visits. Chi-square and t-test compared care quality with seizure control. Logistic regression was used to assess the relationships between SC, quality of care and subspecialist involvement.

RESULTS

Care quality, reflected by documentation of seizure frequency, addressing therapeutic interventions, and referral to a comprehensive epilepsy center, all exceeded 80% adherence. Care quality as reflected by documentation of seizure type, etiology or syndrome; assessment of side effects, counseling about epilepsy safety and women's issues, and screening for psychiatric disorders ranged from 40 to 57%. Mean EQM adherence across all applicable measures was associated with greater seizure control (p=0.0098). DFC was low (=8%) and did not covary with seizure control (p=0.55). The SC and non-SC groups only differed on epilepsy etiology (p=0.04). Exploratory analysis showed that mean quality scores are associated with seizure control (OR=4.9 [1.3-18.5], p=0.017) while controlling for the effect of subspecialty involvement as a possible confounding variable.

CONCLUSIONS

Average quality of care but not defect-free care was associated with seizure control in this retrospective cohort.

Time to change the blind men and the elephant approach to Parkinson disease?

Parkinson disease (PD) is a progressive neurodegenerative disease that is associated with substantial morbidity and early mortality. Disease-related costs exceed $10 billion, not including medications, out-of-pocket expenses, or societal costs. Symptomatic treatment with levodopa, which has been available for over 30 years, and advanced therapies such as deep brain stimulation improve outcomes. Yet most new medications for PD provide a therapeutic benefit that is relatively modest compared to the benefits from levodopa. Despite dozens of neuroprotective clinical trials, there are no medications proven to slow the progression of the disease. Given these limitations, we provide evidence of the potential public health impact of a research agenda that emphasizes identification of risk factors to reduce disease burden through exposure mitigation. In addition, we emphasize health care policy that focuses on increasing health care expenditures for neurologic evaluation and management services to increase access to specialists to improve disease outcomes and reduce costs through better disease management.

Person-Centered Care in the Home Setting for Parkinson's Disease: Operation House Call Quality of Care Pilot Study

Objective. (1) To evaluate the feasibility of implementing and evaluating a home visit program for persons with Parkinson's disease (PD) in a rural setting. (2) To have movement disorders fellows coordinate and manage health care delivery. Background. The University of Florida, Center for Movement Disorders and Neurorestoration established Operation House Call to serve patients with PD who could not otherwise afford to travel to an expert center or to pay for medical care. PD is known to lead to significant disability, frequent hospitalization, early nursing home placement, and morbidity. Methods. This was designed as a quality improvement project. Movement disorders fellows travelled to the home(s) of underserved PD patients and coordinated their clinical care. The diagnosis of Parkinson's disease was confirmed using standardized criteria, and the Unified Parkinson's Disease Rating Scale was performed and best treatment practices were delivered. Results. All seven patients have been followed up longitudinally every 3 to 6 months in the home setting, and they remain functional and independent. None of the patients have been hospitalized for PD related complications. Each patient has a new updatable electronic medical record. All Operation House Call cases are presented during video rounds for the interdisciplinary PD team to make recommendations for care (neurology, neurosurgery, neuropsychology, psychiatry, physical therapy, occupational therapy, speech therapy, and social work). One Operation House Call patient has successfully received deep brain stimulation (DBS). Conclusion. This program is a pilot program that has demonstrated that it is possible to provide person-centered care in the home setting for PD patients. This program could provide a proof of concept for the construction of a larger visiting physician or nurse program.

Quality care in epilepsy: Women's counseling and its association with folic acid prescription or recommendation

OBJECTIVE

This study aimed to determine if annual counseling about contraception and pregnancy in the setting of treatment for epilepsy is associated with increased recommending or prescribing of folate.

METHODS

This is a retrospective cohort study with medical record abstraction. We selected records from 77 women of childbearing age who had two or more visits for epilepsy at a neurology clinic. The assessment included a review of documentation from the first three visits for epilepsy within a 24-month follow-up window. We defined perfect adherence to annual counseling about the impact of epilepsy treatment on contraception or pregnancy as defect-free care for women (DFCW). A recommendation that the patient take over-the-counter folate or a prescription for folate was independently abstracted from the chart at each visit.

RESULTS

The group of patients who received DFCW (N=28, 36.36%) and the group who did not receive DFCW (N=49, 63.63%) were comparable with respect to age, disease duration, baseline history of drug-resistant epilepsy (DRE), presence of concurrent psychiatric disease, epileptologist involvement, number of antiepileptic drugs (AEDs) prescribed, seizure type, and etiology. Twenty (71.4%) patients in the DFCW group and 42 (85.7%) in the non-DFCW group were not recommended or prescribed folic acid (p=0.12).

CONCLUSIONS

Even with annual documentation of counseling about how epilepsy treatment may affect contraception and pregnancy, the "action" of prescribing or recommending folic acid during the ensuing 24months is frequently omitted.

Group Education with Personal Rehabilitation for Idiopathic Parkinson's Disease

Objective:

To evaluate the effect of a group education program with personal rehabilitation for idiopathic Parkinson's disease (IPD).

Methods:

A single-blind, randomized, controlled clinical trial, with a pre-test/post-test quasi-experimental design. Fortyfour stable, non-demented patients with IPD were randomly assigned to an intervention group (n=23) and control group (n=21). Three group lectures on health education specific to IPD were delivered to the intervention group. The theme of lectures was “Not a lonely journey, as your friend, we—experts specializing in IPD— would love to join with you.” Three domains of the management of IPD were mentioned: “How to manage your routine Meal, Moving and Mood after suffering from IPD” Each lecture was scheduled for 45 minutes (excluding breaks), and designed as an interactive dialogue rather than a traditional lecture. To strengthen the impact of the lectures, relevant information was published on a website: http://www.parkinsonism.cn/. Following the group lecture, individualized and tailored rehabilitation made up of 24 half-hour sessions over eight weeks were provided for the intervention group.

Results:

The program ran smoothly and IPD patients were satisfied with this program. After only eight weeks, the health-related quality of life (HR-QOL) in the intervention group improved significantly (p<0.001). Patients and their caregivers in this group also reported their mood elevations following the program.

Conclusion:

Group education combined with personal rehabilitation program appears to be a beneficial and practical intervention, not only complementing the medical treatment for IPD patients but also meeting the growing demand for long-term care.

Virtual house calls for Parkinson disease (Connect.Parkinson): study protocol for a randomized, controlled trial

Background

Interest in improving care for the growing number of individuals with chronic conditions is rising. However, access to care is limited by distance, disability, and distribution of doctors. Small-scale studies in Parkinson disease, a prototypical chronic condition, have suggested that delivering care using video house calls is feasible, offers similar clinical outcomes to in-person care, and reduces travel burden.

Methods/Design

We are conducting a randomized comparative effectiveness study (Connect.Parkinson) comparing usual care in the community to usual care augmented by virtual house calls with a Parkinson disease specialist. Recruitment is completed centrally using online advertisements and emails and by contacting physicians, support groups, and allied health professionals. Efforts target areas with a high proportion of individuals not receiving care from neurologists. Approximately 200 individuals with Parkinson disease and their care partners will be enrolled at 20 centers throughout the United States and followed for one year. Participants receive educational materials, then are randomized in a 1:1 ratio to continue their usual care (control arm) or usual care and specialty care delivered virtually (intervention arm). Care partners are surveyed about their time and travel burden and their perceived caregiver burden. Participants are evaluated via electronic survey forms and videoconferencing with a blinded independent rater at baseline and at 12 months. All study activities are completed remotely.

The primary outcomes are: (1) feasibility, as measured by the proportion of visits completed, and (2) quality of life, as measured by the 39-item Parkinson’s Disease Questionnaire. Secondary outcomes include measures of clinical benefit, quality of care, time and travel burden, and caregiver burden.

Discussion

Connect.Parkinson will evaluate the feasibility and effectiveness of using technology to deliver care into the homes of individuals with Parkinson disease. The trial may serve as a model for increasing access and delivering patient-centered care at home for individuals with chronic conditions.

Trial registration

This trial was registered on clinicaltrials.gov on January 8, 2014 [NCT02038959].

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-465) contains supplementary material, which is available to authorized users.

Telehealth Management in Movement Disorder: A Retrospective Study

Background:

Management of chronic diseases such as movement disorders can be challenging. Nurse-administered telephone follow-up programs have demonstrated clinical and cost efficacy in a variety of health care models. However, their efficacy in movement disorders has not been sufficiently addressed. This observational study fills a knowledge gap by reporting the nature of individuals utilizing a nurse-administered telephone service and the reasons for and the outcomes of calls.

Method:

Consecutive calls received by the clinic for a 12-month duration were recorded. A sample of 312 calls from 132 patient charts was analyzed. Variables for analysis and coding schema were determined a-priori and included demographic information as well as information around the reasons for and outcomes of calls. The narratives of documented calls were reviewed retrospectively and responses coded for analysis by a separate researcher. Data was analyzed using descriptive statistical methods.

Result:

Patients made the majority of calls (49%). 27% of calls related to worsening symptoms and another 35% of calls related to medication issues or renewals. The mean call duration was 15.93 minutes. The majority of calls were received mid-way between clinic visits (M = 89.24 days). The nurse resolved 84% of calls independently. The mean number of calls per patient was 2.93. Issues reported by patients were resolved (approximately 90%) without need for follow-up emergency, family, or subspecialty clinic visits.

Conclusion:

The results underscore the complexity of medical issues in a movement disorders population. The current study provides support for a nurse-administered telephone follow-up program in movement disorders.

The past, present, and future of telemedicine for Parkinson's disease

Travel distance, growing disability, and uneven distribution of doctors limit access to care for most Parkinson's disease (PD) patients worldwide. Telemedicine, the use of telecommunications technology to deliver care at a distance, can help overcome these barriers. In this report, we describe the past, present, and likely future applications of telemedicine to PD. Historically, telemedicine has relied on expensive equipment to connect single patients to a specialist in pilot programs in wealthy nations. As the cost of video conferencing has plummeted, these efforts have expanded in scale and scope, now reaching larger parts of the world and extending the focus from care to training of remote providers. Policy, especially limited reimbursement, currently hinders the growth and adoption of these new care models. As these policies change and technology advances and spreads, the following will likely develop: integrated care networks that connect patients to a wide range of providers; education programs that support patients and health care providers; and new research applications that include remote monitoring and remote visits. Together, these developments will enable more individuals with PD to connect to care, increase access to expertise for patients and providers, and allow more-extensive, less-expensive participation in research.

The current state and needs of north american movement disorders fellowship programs

Background. Movement disorders fellowships are an important source of future clinician-specialists and clinician-scientists for the field. Scant published information exists on the number and characteristics of North American movement disorders fellowship training programs. Methods. A 31-item internet-based survey was formulated and distributed to academic movement disorders listed in the American Academy of Neurology (AAN) directory as having a movement disorders fellowship and to all National Parkinson Foundation Centers of Excellence and Care Centers in North America. Results. There was a 77% response rate among academic movement disorders centers. Broad similarities in clinical training were identified. The two most important rated missions of maintaining a movement disorders fellowship were contributions to scholarly activities and to fulfilling a critical need for specialists. Almost a quarter of fellowship programs did not offer a fellowship slot during the most recent academic year. Fellowship directors cited a wide variety of funding sources, but their top concern was lack of available funding for fellowship programs. Conclusions. North American movement disorders fellowship training programs currently offer similar methods of clinical training and education. Lack of funding was the most important obstacle to maintaining fellowship programs and should be made a priority for discussion in the field.

Randomized controlled clinical trial of "virtual house calls" for Parkinson disease

IMPORTANCE

The burden of neurological disorders is increasing, but access to care is limited. Providing specialty care to patients via telemedicine could help alleviate this growing problem.

OBJECTIVE

To evaluate the feasibility, effectiveness, and economic benefits of using web-based videoconferencing (telemedicine) to provide specialty care to patients with Parkinson disease in their homes.

DESIGN

A 7-month, 2-center, randomized controlled clinical trial.

SETTING

Patients' homes and outpatient clinics at 2 academic medical centers.

PARTICIPANTS

Twenty patients with Parkinson disease with Internet access at home.

INTERVENTION

Care from a specialist delivered remotely at home or in person in the clinic.

MAIN OUTCOME MEASURES

The primary outcome variable was feasibility, as measured by the percentage of telemedicine visits completed as scheduled. Secondary outcome measures included clinical benefit, as measured by the 39-item Parkinson Disease Questionnaire, and economic value, as measured by time and travel.

RESULTS

Twenty participants enrolled in the study and were randomly assigned to telemedicine (n = 9) or in-person care (n = 11). Of the 27 scheduled telemedicine visits, 25 (93%) were completed, and of the 33 scheduled in-person visits, 30 (91%) were completed (P = .99). In this small study, the change in quality of life did not differ for those randomly assigned to telemedicine compared with those randomly assigned to in-person care (4.0-point improvement vs 6.4-point improvement; P = .61). Compared with in-person visits, each telemedicine visit saved participants, on average, 100 miles of travel and 3 hours of time.

CONCLUSION AND RELEVANCE

Using web-based videoconferencing to provide specialty care at home is feasible, provides value to patients, and may offer similar clinical benefit to that of in-person care. Larger studies are needed to determine whether the clinical benefits are indeed comparable to those of in-person care and whether the results observed are generalizable.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01476306.

Utilization of genetic testing prior to subspecialist referral for cerebellar ataxia

OBJECTIVE

To evaluate the utilization of laboratory testing in the diagnosis of cerebellar ataxia, including the completeness of initial standard testing for acquired causes, the early use of genetic testing, and associated clinical and nonclinical factors, among a cohort referred for subspecialty consultation.

METHODS

Data were abstracted from records of 95 consecutive ataxia patients referred to one neurogenetics subspecialist from 2006-2010 and linked to publicly available data on characteristics of referral clinicians. Multivariable logistic and linear regression models were used to analyze unique associations of clinical and nonclinical factors with laboratory investigation of acquired causes and with early genetic testing prior to referral.

RESULTS

At referral, 27 of 95 patients lacked evidence of any of 14 laboratory studies suggested for initial work-up of an acquired cause for ataxia (average number of tests=4.5). In contrast, 92% of patients had undergone brain magnetic resonance imaging prior to referral. Overall, 41.1% (n=39) had genetic testing prior to referral; there was no association between family history of ataxia and obtaining genetic testing prior to referral (p=0.39). The level of early genetic testing was 31.6%, primarily due to genetic testing despite an incomplete laboratory evaluation for acquired causes and no family history. A positive family history was consistently associated with less extensive laboratory testing (p=0.004), and referral by a neurologist was associated with higher levels of early genetic testing.

CONCLUSIONS

Among consecutive referrals to a single center, a substantial proportion of sporadic cases had genetic testing without evidence of a work-up for acquired causes. Better strategies to guide decision making and subspecialty referrals in rare neurologic disorders are needed, given the cost and consequences of genetic testing.

The coming crisis: obtaining care for the growing burden of neurodegenerative conditions

As the U.S. population ages, the burden of neurodegenerative disorders, including Alzheimer disease and Parkinson disease, will increase substantially. However, many of these patients and their families currently do not receive neurologic care. For example, a recent study found that over 40% of Medicare beneficiaries with an incident Parkinson disease diagnosis did not receive neurologist care early after diagnosis and those who did not were more likely to fracture a hip, be placed in a nursing home, and die. While geography, age, race, and sex likely contribute to these observed disparities in care and outcomes, a large barrier may be Medicare's reimbursement policies, which value procedures over care. With further reductions in Medicare reimbursement constantly on the horizon, the devaluing of clinical care will likely continue. Rather than guaranteeing access to care, Medicare's reimbursement policies may increasingly be an impediment to care.

A Patient-Based Needs Assessment for Living Well with Parkinson Disease: Implementation via Nominal Group Technique

Background. Parkinson's disease (PD) is a neurodegenerative condition with complex subtleties, making it challenging for physicians to fully inform their patients. Given that approximately 50% of Americans access the Internet for health information, the development of a multimedia, web-based application emphasizing targeted needs of people with Parkinson's disease (PwP) has the potential to change patient's lives. Objectives. To determine what information PwP perceive could enhance their quality of life. Methods. Group sessions utilizing nominal group technique (NGT) were conducted. Participants were asked “what information do you want to know about that would help you live well with PD?” Silent generation of ideas preceded discussion followed by anonymous ranking of items. A “summary score” (sum of rank × frequency) was calculated. Results. 36 individual items were collapsed into 9 categories. Coping with emotions, changing relationships, and social implications of PD were ranked as most important. Financial supports and skills for self-advocacy were also highly ranked. Conclusions. Qualitative research methodology was utilized to determine the unmet needs of PwP. Results of this survey will inform the development of a patient-oriented, online resource, the goal will be to provide information and strategies to improve symptom management, reduce disability and address all relevant concerns important to those affected by PD.

Move for Change Part II: a European survey evaluating the impact of the EPDA Charter for people with Parkinson's disease

BACKGROUND AND PURPOSE

The Move for Change campaign is a three-part series of pan-European surveys designed by the European Parkinson's Disease Association (EPDA) to assess the impact that the EPDA Charter for People with Parkinson's disease (PD) has had since its launch in 1997. Here, we report results from the second survey, focusing on the third right of the Charter; that is, 'all patients have the right to have access to support services'. Although the level of evidence for different support services varies, it is important to ensure that patients can access services with clinically proven benefits.

METHODS

This survey comprised nine questions administered online via the EPDA and PD organization Web sites. Accessibility of support services was defined as 'services/medication/multidisciplinary healthcare professionals, etc. being available and on hand to patients when required'.

RESULTS

Neurologists and general practitioners (GPs) received highest accessibility results (90.0 and 87.0% of respondents, respectively), with moderate results for physiotherapists (68.0%) and PD organizations (72.0%) and lower results for PD specialist nurses (26.0%), occupational therapists (23.0%), and counselors (27.0%). Support provided by neurologists and PD specialists was considered to be 'very helpful' by 59.0 and 55.7%, respectively, whilst only 31.8% of respondents gave such favorable ratings to GPs. Funding of services was variable across Europe.

CONCLUSIONS

These data demonstrate the challenges faced by PD patients in accessing the adequate care and support required throughout the course of their disease. These findings can assist healthcare professionals and policymakers in improving access to support services for patients and their families across Europe.

Move for change part I: a European survey evaluating the impact of the EPDA Charter for People with Parkinson's disease

BACKGROUND AND PURPOSE

The 1997 European Parkinson's Disease Association's (EPDA) Charter for People with Parkinson's disease (PD) outlines their rights in terms of standards of care. It states that all patients have the right to: be referred to a doctor with a special interest in PD; receive an accurate diagnosis; have access to support services; receive continuous care; and take part in managing their illness. Move for Change is a three-part series of pan-European patient surveys based on this Charter.

METHODS

This first survey, consisting of 23 questions, focusing on the initial two points of the Charter, was administered online through the EPDA and affiliated patient associations' Web sites. Of 2149 forms received from 35 European countries, 2068 (96.2%) were analyzed, with the remainder excluded, mainly due to incomplete responses.

RESULTS

The majority of patients were diagnosed within 2 years from the onset of first symptoms (82.7%; range, <1 year to ≥5 years). In relation to diagnosis delivery, 45.3% of patients stated that it was 'poor' or 'very poor'. During the 2 years following diagnosis, 43.8% of respondents had never seen a PD specialist. Care was usually overseen by generically active neurologists (92.5%) or family doctors (81.0%), with considerable overlap between the two.

CONCLUSIONS

  These data highlight challenges that patients with PD face during the period of diagnosis, despite introduction of the Charter. These findings can assist healthcare professionals and policy makers in improving the level of care for patients and their families across Europe, and we offer suggestions about how this can be achieved.