A pilot study of telemedicine for new neurological outpatient referrals

Evaluation of telemedicine for new outpatient neurological consultations

Objective

The COVID-19 pandemic has broadened the use of teleneurology, how this compares with face-to-face (F2F) clinics is unclear. This study compared virtual with F2F new neurological consultations.

Methods

We retrospectively evaluated new outpatient consultations in neurology clinics in Aberdeen Royal Infirmary. We compared sociodemographic data, time to consultation, time to diagnosis, the need for reassessment and re-investigation between traditional F2F and virtual clinics using the web-based Attend Anywhere platform or telephone into patients’ own homes (or chosen location) without a trained assistant. We calculated the relative risk (RR) of the need for reassessment and re-investigation over 6-month periods by the suspected neurological diagnosis.

Results

73% of consultations were virtual (Attend Anywhere or telephone) between June and October 2020, this was almost non-existent (<0.1%) in June–October 2019. We analysed 352 F2F (June–July 2019) and 225 virtual consultations (June–July 2020). Compared with F2F clinics, virtual clinics had a longer time to diagnosis (p=0.019), were more likely to be reassessed (RR: 2.2, 95% CI: 1.5 to 3.2; p<0.0001) and re-investigated (RR: 1.50, 95% CI: 0.88 to 2.54; p=0.133), this was likelier in those aged ≥60 years. Patients with headaches and suspected seizures were less likely to need reassessment or re-investigation following virtual clinics than multiple sclerosis and neuroinflammatory disorders, spinal cord disorders and functional neurological disorders.

Conclusion

This study demonstrates that virtual clinics have higher rates of reassessment and re-investigation than F2F clinics. As virtual clinics become a potential consultation alternative, this study should instruct the selection of patients for either consultation type.

The University of Colorado Virtual Physical Examination for Spine Surgeons: A Preliminary Study

As coronavirus disease 2019 (COVID-19) reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical examination in a specialty reliant on direct patient contact for diagnosis and treatment. A prospective cohort of 52 patients consented to participate in a novel virtual physical examination protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the tele-medicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical examination and survey. Males and females were distributed evenly among the cohort at 50%. The mean age was 52.1±15.5 years. The average score for ease of understanding the examination (1=easiest, 5=hardest) was 1.1, while the average score for ease of performance was 1.5. Most participants (97.56%) felt their provider was better able to understand their condition using the virtual examination findings. This study highlights the utility of a virtual physical examination for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an examination can be implemented and performed to improve patient evaluation and satisfaction. [Orthopedics. 2022;45(1):e7-e10.].

Fifth Generation Cellular Networks and Neurosurgery: A Narrative Review

Connectivity is a driving force for productivity across a wide variety of sectors in the 21st century, with health care being no exception. Fifth generation cellular technology (5G) is frequently alluded to in the mainstream media but understanding of the technology and its potential impact is not widespread in clinical communities. It promises unprecedented improvement in speed, bandwidth, reliability, and latency, all of which have significant implications for the way we use wireless data. 5G can be subdivided into 3 parallel technological architectures: extended mobile broadband (eMBB), ultra-reliable low latency communication (URLLC), and massive machine type communication (mMTC). These domains each present different and exciting prospects for the future of health care. This narrative review aims to elucidate the nature of 5G, its context within the development of telecommunications, and describe some of the notable opportunities it presents to the neurosurgical community. In many cases the requisite hardware has already been developed, but use has been limited by the requirements of a fast, reliable, and omnipresent network connection. Examples include telesurgical robots, remote supervision of procedures, integrated smart operating rooms, and clinician telepresence. The events of 2020 and the COVID-19 pandemic have brought the world's attention to digital transformation. The mechanics of 5G connectivity creates the capacity for these changes to be applied practically. An understanding of this technology is essential to appreciate the development and opportunities which will be part of our professional future.

Management of patients with neuromuscular disorders at the time of the SARS-CoV-2 pandemic

The novel Coronavirus disease-19 (COVID-19) pandemic has posed several challenges for neuromuscular disorder (NMD) patients. The risk of a severe course of SARS-CoV-2 infection is increased in all but the mildest forms of NMDs. High-risk conditions include reduced airway clearance due to oropharyngeal weakness and risk of worsening with fever, fasting or infection Isolation requirements may have an impact on treatment regimens administered in hospital settings, such as nusinersen, glucosidase alfa, intravenous immunoglobulin, and rituximab infusions. In addition, specific drugs for SARS-CoV2 infection under investigation impair neuromuscular function significantly; chloroquine and azithromycin are not recommended in myasthenia gravis without available ventilatory support and prolonged prone positioning may influence options for treatment. Other therapeutics may affect specific NMDs (metabolic, mitochondrial, myotonic diseases) and experimental approaches for Coronavirus disease 2019 may be offered "compassionately" only after consulting the patient's NMD specialist. In parallel, the reorganization of hospital and outpatient services may change the management of non-infected NMD patients and their caregivers, favouring at-distance approaches. However, the literature on the validation of telehealth in this subgroup of patients is scant. Thus, as the first wave of the pandemic is progressing, clinicians and researchers should address these crucial open issues to ensure adequate caring for NMD patients. This manuscript summarizes available evidence so far and provides guidance for both general neurologists and NMD specialists dealing with NMD patients in the time of COVID-19.

The Use of Patient-Facing Teleconsultations in the National Health Service: Scoping Review

BACKGROUND

The National Health Service (NHS) Long-Term Plan has set out a vision of enabling patients to access digital interactions with health care professionals within 5 years, including by video link.

OBJECTIVE

This review aimed to examine the extent and nature of the use of patient-facing teleconsultations within a health care setting in the United Kingdom and what outcome measures have been assessed.

METHODS

We conducted a systematic scoping review of teleconsultation studies following the Joanna Briggs Institute methodology. PubMed, Scopus, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were searched up to the end of December 2018 for publications that reported on the use of patient-facing teleconsultations in a UK health care setting.

RESULTS

The search retrieved 3132 publications, of which 101 were included for a full review. Overall, the studies were heterogeneous in design, in the specialty assessed, and reported outcome measures. The technology used for teleconsultations changed over time with earlier studies employing bespoke, often expensive, solutions. Two-thirds of the studies, conducted between 1995 and 2005, used this method. Later studies transitioned to Web-based commercial solutions such as Skype. There were five outcome measures that were assessed: (1) technical feasibility, (2) user satisfaction, (3) clinical effectiveness, (4) cost, (5) logistical and operational considerations. Due to the changing nature of technology over time, there were differing technical issues across the studies. Generally, teleconsultations were acceptable to patients, but this was less consistent among health care professionals. However, among both groups, face-to-face consultations were still seen as the gold standard. A wide range of clinical scenarios found teleconsultations to be clinically useful but potentially limited to more straightforward clinical interactions. Due to the wide array of study types and changes in technology over time, it is difficult to draw definitive conclusions on the cost involved. However, cost savings for health care providers have been demonstrated by the goal-directed implementation of teleconsultations. The integration of technology into routine practice represents a complex problem with barriers identified in funding and hospital reimbursement, information technologies infrastructure, and integration into clinicians' workflow.

CONCLUSIONS

Teleconsultations appear to be safe and effective in the correct clinical situations. Where offered, it is likely that patients will be keen to engage, although teleconsultations should only be offered as an option to support traditional care models rather than replace them outright. Health care staff should be encouraged and supported in using teleconsultations to diversify their practice. Health care organizations need to consider developing a digital technology strategy and implementation groups to assist health care staff to integrate digitally enabled care into routine practice. The introduction of new technologies should be assessed after a set period with service evaluations, including feedback from key stakeholders.

Headache patients' satisfaction with telemedicine: a 12-month follow-up randomized non-inferiority trial

BACKGROUND AND PURPOSE

We investigated non-acute headache patients' long-term satisfaction with a telemedicine consultation and consultation preferences in northern Norway. We hypothesized that patients were not less satisfied with telemedicine than traditional consultations. We also examined the influence of gender, age and education on satisfaction.

METHODS

For 2.5 years, patients were consecutively screened, recruited and randomly assigned to telemedicine or traditional visits with a consultation at a neurological outpatient department. The primary endpoint was frequency of satisfied patients at 3 and 12 months. Secondary endpoints were satisfaction with consultation, communication, information, diagnosis, advice and prescriptions, and preferred visit form at 12 months.

RESULTS

Of 402 participants, 279 (69.4%) answered questionnaires at both 3 and 12 month, and 291 (72.4%) responded at 12 months. The long-term satisfaction of telemedicine patients was 124/145 (85.5%) compared with 118/134 (88.1%) in the traditional group (P = 0.653). The groups did not differ with respect to secondary endpoints, but females were more satisfied with telemedicine communication (P = 0.027). In the telemedicine group, 99/147 (67.3%) were indifferent to the type of consultation. Age and education did not alter the primary results.

CONCLUSIONS

At 1 year after a specialist evaluation for headache, telemedicine patients did not express less satisfaction than those with traditional consultation. Telemedicine specialist consultations may be a good alternative for headache patients in secondary care.

Telemedicine in the management of non-acute headaches: A prospective, open-labelled non-inferiority, randomised clinical trial

Objectives We determined headache patients' satisfaction with telemedicine and assessed how telemedicine influenced headache burden, compliance with diagnosis and treatment, and need for follow-up consultations. Methods During 2.5 years, patients from Northern Norway referred with non-acute headaches for a specialist consultation at Tromsø University Hospital were consecutively randomised to either telemedicine or traditional visits. Baseline data were recorded and compared to data from a three-month follow-up questionnaire (see Supplementary material). The following were evaluated: (1) satisfaction with the consultation; (2) headache status; subjective improvement, average pain intensity, treatment, headache days per month, and Headache Impact Test (HIT-6); and (3) treatment compliance and follow-up visits. Results Out of 402 consultations, 348 (86.6%) answered the questionnaire. Satisfaction was similar in the telemedicine and the traditional group (88.8% vs. 92.3%; p = 0.35). Subgroup analyses were not prespecified, but there were no differences in satisfaction among females, migraineurs, rural patients and urban patients. Improvement from baseline after three months was reported equally in the telemedicine and the traditional groups. There were also no differences in treatment compliance, but rural telemedicine patients had less-frequent headache visits at three months' follow-up (28.9% vs. 48.7%, p = 0.002). Conclusion Telemedicine is non-inferior to traditional consultations in patient satisfaction, specialist evaluation, and treatment of non-acute headaches. ClinicalTrials.gov ID: NCT02270177.

Acceptability, Feasibility, and Cost of Telemedicine for Nonacute Headaches: A Randomized Study Comparing Video and Traditional Consultations

Background

The feasibility of telemedicine in diagnosing and treating nonacute headaches, such as primary headaches (migraine and tension-type) and medication-overuse headaches has not been previously investigated. By eliminating the need of travel to specialists, telemedicine may offer significant time and money savings.

Objectives

Our objective was to estimate the acceptance of telemedicine and investigate the feasibility and cost savings of telemedicine consultations in diagnosing and treating nonacute headaches.

Methods

From September 2012 to March 2015, nonacute headache patients from Northern Norway who were referred to neurologists through an electronic application system were consecutively screened and randomized to participate in either telemedicine or traditional specialist visits. All patients were consulted by two neurologists at the neurological department in Tromsø University Hospital. Feasibility outcomes were compared between telemedicine and traditional groups. Baseline characteristics and costs were then compared between rural and urban patients. Travel costs were calculated by using the probabilistic method of the Norwegian traveling agency: the cheapest means of public transport for each study participant. Loss of pay was calculated based on the Norwegian full-time employee’s average salary: < 3.5 hours=a half day’s salary, > 3.5 hours spent on travel and consultation=one day’s salary. Distance and time spent on travel were estimated by using Google Maps.

Results

Of 557 headache patients screened, 479 were found eligible and 402 accepted telemedicine participation (83.9%, 402/479) and were included in the final analyses. Of these, 202 received traditional specialist consultations and 200 received telemedicine. All patients in the telemedicine group were satisfied with the video quality, and 198 (99%, 198/200) were satisfied with the sound quality. The baseline characteristics as well as headache diagnostics and follow-up appointments, and the investigation, advice, and prescription practices were not statistically different between the two randomized groups. In addition, telemedicine consultations were shorter than traditional visits (38.8 vs 43.7 min, P<.001).

The travel cost per rural individual (292/402, 73%) was €249, and estimated lost income was €234 per visit. The travel cost in the urban area (110/402, 27%) was €6, and estimated lost income was €117 per visit. The median traveling distance for rural patients was 526 km (range 1892 km), and the median traveling time was 7.8 hours (range 27.3 hours). Rural patients had a longer waiting time than urban patients (64 vs 47 days, P=.001), and fewer women were referred from rural areas (P=.04). Rural women reported higher pain scores than urban women (P=.005).

Conclusion

Our study shows that telemedicine is an accepted, feasible, time-saving, and cost-saving alternative to traditional specialist consultations for nonacute headaches.

Trial Registration

Clinicaltrials.gov NCT02270177; http://clinicaltrials.gov/ct2/show/NCT02270177 (Archived by WebCite at http://www.webcitation.org/6hmoHGo9Q)

Teleneurology: successful delivery of chronic neurologic care to 354 patients living remotely in a rural state

BACKGROUND

Delivery of specialty healthcare to rural citizens in the United States remains largely unmet. The Veterans Health Administration is in a unique position to deliver specialty care to rural Veterans because it is mandated to deliver medical care to all eligible Veterans regardless of residence. To accomplish this, the VHA developed large national telehealth networks that provided over 1 million episodes of care in 2012. We investigated whether clinical video telehealth technologies can provide quality efficient neurologic follow-up care to Veterans living in the rural southwest United States.

PATIENTS AND METHODS

Veterans with chronic neurologic conditions living remotely in New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 11 rural community-based outpatient clinics following initial evaluation at the Albuquerque, NM, neurology outpatient clinic.

RESULTS

Over a 2-year period, 87% of 354 consecutive patients returned a performance improvement satisfaction questionnaire. Ninety percent of the patients were fully satisfied with their visit, and 92% felt teleneurology saved them time and money. We calculated an average time savings of 5 h and 325 miles driven, plus at least $48,000 total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology.

CONCLUSIONS

Our study confirms earlier pilot studies of successful follow-up care through telemedicine. Our patients were highly satisfied with the convenience and quality of their teleneurology visit, and the neurology providers were convinced that neurologic care to both teleneurology and clinic follow-up patients was equivalent. Teleneurology to rural Veterans can provide quality neurologic care and overwhelming patient satisfaction and save considerable time and money.

A systematic review of studies concerning observer agreement during medical specialist diagnosis using videoconferencing

We conducted a systematic review of studies of observer agreement for medical specialist diagnosis via videoconferencing. The review was based on searches of electronic databases and a hand search of relevant journals and reference lists between 1966 and June 2010. There were 20 studies comparing videoconferencing diagnosis with a non-telemedicine alternative by reporting a measure of agreement. Half of the studies were in the field of dermatology; these studies provided solid support for the reliability of videoconferencing. The other 10 studies were in psychiatry, geriatrics, minor injuries, neurology and rheumatology. Reliability of diagnosis via videoconferencing was confirmed in all studies. In the studies where physical examination was an element of the diagnostic process, results were reliable but authors recommended greater care during the diagnostic process (e.g. good equipment, onsite support, additional camera angles). Four studies incorporated a second group to measure agreement in paired face-to-face assessments. Although useful evidence for the reliability of diagnosis via videoconferencing was provided by the studies in the review, the range of medical specialties was small. The variation in research methodology and statistical analysis suggests a lack of clarity about which research design is appropriate for measuring observer agreement in relation to diagnostic reliability.

Teleneurology in patients with multiple sclerosis: EDSS ratings derived remotely and from hands-on examination

We compared the telemedicine assessment of 20 patients with multiple sclerosis (MS) with the findings of a hands-on examiner. The remote specialist was a neurologist with expertise in MS; the hands-on examination was performed by an experienced mid-level practitioner. We also compared the findings of a second specialist viewing the examination in the room with the patient. The videoconference link operated at a bandwidth of 384 kbit/s. All three examiners independently completed a standardized rating scale for neurological functions. Cronbach's alpha for the three raters' total expanded disability status scale (EDSS) score was 0.99 with individual correlations ranging from 0.96-0.97. Agreement between raters for individual neurological domain scores was more variable. The most consistent assessments were for optic, bowel and bladder, and cerebral functions. The least consistent were for cerebellar and brain stem functions. Agreement between the remote and local examiners was similar to that reported for different neurological examiners directly assessing the same patient using the EDSS rating system.

Telehealth videoconferencing: improving home parenteral nutrition patient care to rural areas of Ontario, Canada

BACKGROUND

Telehealth videoconferencing is a medium for health care professionals to communicate and care for patients living in remote areas. The aim of this study was to provide a survey to examine management outcome of home parenteral nutrition (HPN) patients when followed by telehealth as an alternative modality of care.

METHODS

Twenty-six individuals who were identified to benefit from tele-health were invited to participate in a satisfaction survey. The survey was sent to patients by postal mail. The survey also documented the incidence of line sepsis and other medical HPN complications. A cost analysis was also performed according to technology, human resources, and infrastructure.

RESULTS

Eighty-one telehealth videoconference sessions have been held since the inception of telehealth in 2002. Of the current telehealth patients, 13 were eligible for the survey. The satisfaction survey response rate was 11/13 (84.6%). The average line sepsis rate for the 13 patients was 0.89/1000 catheter-days. All patients were generally satisfied with videoconferencing as an alternative method of communication and care for new consultation, patient and family education, and follow-up. Travel time and costs to the patients, their families, and the health care system were significantly less. For example, a patient who resides 611 km from Toronto would cost CDN (Canadian) 724.00 dollars for flight and accommodation to meet with the team at the HPN clinic in Toronto.

CONCLUSION

Telehealth incorporated the cost-saving ability for HPN patients to maintain proper medical care, support, and collaboration of specialists inaccessible to their local community. Thus, its strongly positive role in HPN care deserves further consideration for a national application.

Diagnosis, access and outcomes: Update of a systematic review of telemedicine services

Telemedicine services are being increasingly used. Although insurers and other payers are covering some services in the USA, the rationale for these coverage decisions is not always evidence-based. We reviewed the literature for telemedicine services that substitute for face-to-face medical diagnosis and treatment. We focused on three types of telemedicine services: store-and-forward, home-based and office/hospital-based services. Studies were included if they were relevant to at least one of the three study areas, addressed at least one key question and contained reported results. We excluded articles that did not study a service requiring face-to-face encounters (i.e. teleradiology was excluded). Our search initially identified 4083 citations. After review, 597 were judged to be potentially relevant at the title/abstract level. Following a full-text review, 106 studies were included. Store-and-forward services have been studied in many specialties, the most common being dermatology, wound care and ophthalmology. The evidence for their efficacy is mixed. Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. Studies of office/hospital-based telemedicine suggest that telemedicine is most effective for verbal interactions, e.g. videoconferencing for diagnosis and treatment in specialties like neurology and psychiatry. There are still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence. Further well-designed research is necessary to understand how best to deploy telemedicine services in health care.

Telemedicine and neurosciences

It is well known that in most countries there is a perennial shortage of specialists in neurosciences. The available neurologists and neurosurgeons are clustered in the metropolitan, urban areas. Those living in suburban and rural areas may have limited or no access to neurological care. Concurrently, there has been an unprecedented growth in information and communication technology (ICT). In this article, the author will demonstrate how the practice of neurosciences will change, with increasing use of telemedicine and ICT. In addition to presenting the author's personal experience, the literature on telemedicine in neurosciences is reviewed.

Changes in diagnosis, treatment, and clinical improvement among patients receiving telemedicine consultations

The aim of this study was to determine whether outpatient telemedicine specialty consultations to primary care clinicians result in changes in a patient's diagnosis, treatment management, and clinical outcomes. Medical records of patients who received two or more clinical telemedicine consultations in dermatology, psychiatry, and endocrinology were evaluated in a nonconcurrent retrospective analysis. Three indicators were used to measure changes in the processes of care and clinical outcomes: change in diagnosis, change in treatment, and patient clinical improvement. A retrospective review of 223 individual telemedicine patient medical records was conducted. Specialty telemedicine consultations were found to result in changes in diagnoses in 48% of the cases, changes in treatment therapy in 81.6% of the cases, and clinical improvement in 60.1%. These results are consistent with previous literature that has assessed changes in processes of care and outcomes from face-to-face specialty consultations in outpatient clinics. Changes in diagnosis and treatment therapy were found to be associated with clinical improvement with odds ratios (ORs) of 2.66 (95% confidence interval [CI]: 1.47-4.83) and 11.22 (95% CI: 4.49-31.48), respectively. This study found that telemedicine consultations resulted in changes in diagnosis and treatment regimens and also are associated with clinical improvements.

Teleneurology to Improve Stroke Care in Rural Areas

Background and Purpose— Assessing both stroke patients and their CT scans by using a conventional videoconference system offers an interesting opportunity to improve stroke care in rural areas. However, until now there have been no studies to suggest whether this method is feasible in routine stroke management.

Methods— Seven rural hospitals in the southern part of Germany in Swabia were connected to the stroke unit of Günzburg with the use of a videoconference link (Telemedicine in Stroke in Swabia [TESS] Project). The local physicians are free to present every admitted stroke patient to the Günzburg stroke expert, who can assess the clinical status and CT images, thereafter giving therapeutic recommendations. All teleconsultations are rated concerning transmission quality and relevance of telemedicine for stroke management.

Results— A total of 153 stroke patients were examined by teleconsultation. Mean age was 67.5 years. Eighty-seven patients had suffered an ischemic stroke, 9 had an intracerebral hemorrhage, and 17 suffered a transient ischemic attack. Forty patients were revealed to have a diagnosis other than stroke. Duration of teleconsultation was 15 minutes on average. User satisfaction was good concerning imaging and audio quality, and patient satisfaction was very good or good in all cases. Relevant contributions could be made in >75% of the cases concerning diagnostic workup, CT assessment, and therapeutic recommendations.

Conclusions— Teleconsultation using a videoconference system seems to be a feasible and promising method to improve stroke care in rural areas where management in a stroke unit is hindered by long transportation distances.

Randomised controlled trial of telemedicine for new neurological outpatient referrals

OBJECTIVE

To test the hypothesis that telemedicine for new patient referrals to neurological outpatients is as efficient and acceptable as conventional face to face consultation.

METHODS

A randomised controlled trial between two groups: face to face (FF) and telemedicine (TM). This study was carried out between a neurological centre and outlying clinics at two distant hospitals linked by identical medium cost commercial interactive video conferencing equipment with ISDN lines transmitting information at 384 kbits/s. The same two neurologists carried out both arms of the study. Of the 168 patients who were suitable for the study, 86 were randomised into the telemedicine group and 82 into the face to face group. Outcome measures were (1) consultation process: (a) number of investigations; (b) number of drugs prescribed; (c) number of patient reviews and (2) patient satisfaction: (a) confidence in consultation; (b) technical aspects of consultation; (c) aspects surrounding confidentiality. Diagnostic categories were also measured to check equivalence between the groups: these were structural neurological, structural non-neurological, non-structural, and uncertain.

RESULTS

Diagnostic categories were similar (p>0.5) between the two groups. Patients in the telemedicine group had significantly more investigations (p=0.001). There was no difference in the number of drugs prescribed (p>0.5). Patients were generally satisfied with both types of consultation process except for concerns about confidentiality and embarrassment in the telemedicine group (p=0.017 and p=0.005 respectively).

CONCLUSION

Telemedicine for new neurological outpatients is possible and feasible but generates more investigations and is less well accepted than face to face examination.