Interdisciplinary Telemedicine Services for Huntington's Disease: A 20-Year Experience

Real-world experience with Deutetrabenazine management in patients with Huntington's disease using video-based telemedicine

BACKGROUND

Huntington's disease (HD) is a rare progressive neurological disorder, and telemedicine has the potential to improve the quality of care for patients with HD. Deutetrabenazine (DTBZ) can reduce chorea symptoms in HD; however, there is limited experience with this medication in Asian countries.

METHODS

Retrospective and prospective studies were employed to explore the feasibility and reliability of a video-based telemedicine system for HD patient care. Reliability was demonstrated through consistency between selected-item scores (SIS) and total motor scores (TMS) and the agreement of scores obtained from hospital and home videos. Finally, a single-centre real-world DTBZ management study was conducted based on the telemedicine system to explore the efficacy of DTBZ in patients with HD.

RESULTS

There were 77 patients included in the retrospective study, and a strong correlation was found between SIS and TMS (r = 0.911, P < 0.0001), indicating good representativeness. There were 32 patients enrolled in the prospective study. The reliability was further confirmed, indicated by correlations between SIS and TMS (r = 0.964, P < 0.0001) and consistency of SIS derived from the in-person and virtual visits (r = 0.969, P < 0.0001). There were 17 patients included in the DTBZ study with a mean 1.41 (95% confidence interval, 0.37-2.46) improvement in chorea score and reported treatment success.

CONCLUSIONS

A video-based telemedicine system is a feasible and reliable option for HD patient care. It may also be used for drug management as a supplementary tool for clinical visits.

Patient experiences receiving rehabilitation care via telehealth: Identifying opportunities for remote care

Use of telehealth has grown substantially in recent times due to the COVID-19 pandemic. Remote care services may greatly benefit patients with disabilities; chronic conditions; and neurological, musculoskeletal, and pain disorders, thereby allowing continuity of rehabilitation care, reducing barriers such as transportation, and minimizing COVID-19 exposure. In March 2020, our rehabilitation hospital, Shirley Ryan AbilityLab, launched a HIPAA-compliant telemedicine program for outpatient and day rehabilitation clinics and telerehabilitation therapy programs. The objective of this study was to examine patients' experiences and satisfaction with telemedicine in the rehabilitation physician practice, including novel virtual multidisciplinary evaluations. The present study examines survey data collected from 157 patients receiving telemedicine services at Shirley Ryan AbilityLab from December 2020-August 2021. Respondents were 61.8% female, predominantly White (82.2%) with ages ranging across the lifespan (69.4% over age 50 years). Diagnostic categories of the respondents included: musculoskeletal conditions 28%, chronic pain 22.3%, localized pain 10.2%, neurological conditions 26.8%, and Parkinson's and movement disorders 12.7%. Survey responses indicate that the telemedicine experiences were positive and well received. The majority of participants found these services easy to use, effective, and safe, and were overall satisfied with the attention and care they received from the providers-even for those who had not previously used telehealth. Respondents identified a variety of benefits, including alleviating financial and travel-related burdens. There were no significant differences in telehealth experiences or satisfaction across the different clinical diagnostic groups. Respondents viewed the integrated physician and rehabilitation therapist telehealth multidisciplinary model favorably, citing positive feedback regarding receiving multiple perspectives and recommendations, feeling like an integrated member of their healthcare team, and having a comprehensive, holistic team approach along with effective communication. These findings support that telemedicine can provide an effective care model in physiatry (physical medicine and rehabilitation) clinics, across different neurological, musculoskeletal, and pain conditions and in multidisciplinary team care settings. The insights provided by the present study expand our understanding of patient experiences with remote care frameworks for rehabilitation care, while controlling for institutional variation, and ultimately will help provide guidance regarding longer term integration of telemedicine in physiatry and multidisciplinary care models.

Primary Palliative Care in Huntington's Disease

Background

Palliative care practices, including communication about patient-centered goals of care and advance care planning (ACP), have the potential to enhance care throughout the course of Huntington's disease (HD) and related disorders. The goal of our project was to develop a pilot program that integrates primary palliative care practices with interdisciplinary care for HD.

Objectives

(1) To train HD team members to facilitate goals of care and ACP conversations at all stages of HD; (2) To create materials for care planning in HD focused on patient-centered goals of care and health-related quality of life; and (3) To modify clinic workflow to include goals of care and ACP discussions.

Methods

We defined planning domains to expand care planning beyond end-of-life concerns. We created a patient and family guide to advance care planning in HD. We conducted VitalTalk communications training with the HD team. We modified the interdisciplinary clinic workflow to include ACP and developed an EMR template for documentation.

Results

After communication training, more team members felt well prepared to discuss serious news (12.5% to 50%) and manage difficult conversations (25% to 62.5%). The proportion of clinic visits including advance care planning discussions increased from 12.5% to 30.6% during the pilot phase.

Conclusions

Provision of primary palliative care for HD in an interdisciplinary clinic is feasible. Integration of palliative care practices into HD specialty care requires additional training and modification of clinic operations.

Improving Patient Outreach by Defining Telehealth Suitability in a Tertiary Huntington's Disease Clinic

BACKGROUND

The COVID-19 pandemic has increased the need for remote healthcare options among patients with Huntington's disease (HD). However, since not every HD patient is suitable for telehealth, it is important to differentiate who can be seen virtually from who should remain as in-person. Unfortunately, there are no clinical guidelines on how to evaluate HD patients for telehealth eligibility.

OBJECTIVE

To standardize the teleneurology selection process in HD by implementing a screening tool that accounts for patient-specific factors.

METHODS

We organized various indications and contraindications to teleneurology into a flowchart. If any indications or contraindications were met, patients were assigned to telehealth or maintained as in-person, respectively. If no indications or contraindications were met, patients were given the option of telehealth or in-person for their upcoming appointments. In two implementation cycles, we tested this screening tool among all HD patients scheduled for clinic visits, aided by chart review and phone interview.

RESULTS

In a cohort of 81 patients, telehealth acceptance among eligible patients increased from 45.0%to 83.3%. Frequency of telehealth visits increased from a pre-intervention baseline of 12.8%to 28.2%.

CONCLUSION

Teleneurology utilization among HD patients more than doubled across our study. Our intervention promotes consistency and patient-centeredness in HD clinical care and streamlines the overall telehealth selection process. Future studies can seek to reduce telehealth no-shows and also evaluate the utility of the motor and psychiatric criteria included in our screening tool.