A comparison of telemedicine and in-person neurology visits: what are the factors that patients consider when selecting future visit type?

Objective

To identify factors that patients consider when choosing between future in-person, video, or telephone visits.

Background

Telemedicine has been rapidly integrated into ambulatory neurology in response to the COVID-19 pandemic.

Methods

Ambulatory neurology patients at a single center were contacted via telephone to complete: (1) a survey quantifying likelihood of scheduling a future telemedicine visit, and (2) a semi-structured qualitative interview following their visit in March 2021. Data were processed using the principles of thematic analysis.

Results

Of 2493 visits, 39% assented to post-visit feedback; 74% were in-person visits and 13% video and telephone. Patients with in-person visits were less likely than those with video and telephone visits to “definitely” consider a future telemedicine visit (36 vs. 59 and 62%, respectively; p < 0.001). Patients considered five key factors when scheduling future visits: “Pros of Visit Type,” “Barriers to Telemedicine,” “Situational Context,” “Inherent Beliefs,” and “Extrinsic Variables.” Patients with telemedicine visits considered convenience as a pro, while those with in-person visits cited improved quality of care. Accessibility and user familiarity were considered barriers to telemedicine by patients with in-person and telephone visits, whereas system limitations were prevalent among patients with video visits. Patients agreed that stable conditions can be monitored via telemedicine, whereas physical examination warrants an in-person visit. Telemedicine was inherently considered equivalent to in-person care by patients with telephone visits. Awareness of telemedicine must be improved for patients with in-person visits.

Conclusion

Across visit types, patients agree that telemedicine is convenient and effective in many circumstances. Future care delivery models should incorporate the patient perspective to implement hybrid models where telemedicine is an adjunct to in-person visits in ambulatory neurology.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11149-0.

Patient Experiences With Ambulatory Telehealth in Neurology: Results of a Mixed-Methods Study

Objective

To assess patient experiences with rapid implementation of ambulatory telehealth during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

A mixed-methods study was performed to characterize the patients' experience with neurology telehealth visits during the first 8 weeks of the COVID-19 response. Consecutive patients who completed a telehealth visit were contacted by telephone. Assenting patients completed a survey quantifying satisfaction with the visit followed by a semistructured telephone interview. Qualitative data were analyzed using the principles of thematic analysis.

Results

A total of 2,280 telehealth visits were performed, and 753 patients (33%) were reached for postvisit feedback. Of these, 47% of visits were by video and 53% by telephone. Satisfaction was high, with 77% of patients reporting that all needs were met, although only 51% would consider telehealth in the future. Qualitative themes were constructed, suggesting that positive patient experiences were associated not only with the elimination of commute time and associated costs but also with a positive physician interaction. Negative patient experiences were associated with the inability to complete the neurologic examination. Overall, patients tended to view telehealth as a tool that should augment, and not replace, in-person visits.

Conclusion

In ambulatory telehealth, patients valued convenience, safety, and physician relationship. Barriers were observed but can be addressed.

What Drives Greater Assimilation of Telestroke in Emergency Departments?

OBJECTIVE

Although many emergency departments (EDs) have telestroke capacity, it is unclear why some EDs consistently use telestroke and others do not. We compared the characteristics and practices of EDs with robust and low assimilation of telestroke.

METHODS

We conducted semi-structured interviews with representatives of EDs that received telestroke services from 10 different networks and had used telestroke for a minimum of two years. We used maximum diversity sampling to select EDs for inclusion and applied a positive deviance approach, comparing programs with robust and low assimilation. Data collection was informed by the Consolidated Framework for Implementation Research. For the qualitative analysis, we created site summaries and conducted a supplemental matrix analysis to identify themes.

RESULTS

Representatives from 21 EDs with telestroke, including 11 with robust assimilation and 10 with low assimilation, participated. In EDs with robust assimilation, telestroke workflow was highly protocolized, programs had the support of leadership, telestroke use and outcomes were measured, and individual providers received feedback about their telestroke use. In EDs with low assimilation, telestroke was perceived to increase complexity, and ED physicians felt telestroke did not add value or had little value beyond a telephone consult. EDs with robust assimilation identified four sets of strategies to improve assimilation: strengthening relationships between stroke experts and ED providers, improving and standardizing processes, addressing resistant providers, and expanding the goals and role of the program.

CONCLUSION

Greater assimilation of telestroke is observed in EDs with standardized workflow, leadership support, ongoing evaluation and quality improvement efforts, and mechanisms to address resistant providers.

Rapid Implementation of Outpatient Teleneurology in Rural Appalachia: Barriers and Disparities

Objective

To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States.

Methods

A retrospective cohort of consecutive patients seen in the first 4 weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video, and when unable, phone-only visits were scheduled. Patients were divided into 2 groups based on the telehealth visit type: video or phone only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured postvisit telephone call.

Results

Of 1,011 telehealth patient visits, 44% were video and 56% phone only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p < 0.001), more likely to be female (63% vs 55%, p < 0.007), be White or Caucasian (p = 0.024), and not have Medicare or Medicaid insurance (p < 0.001). The most common barrier to scheduling video visits was technology limitations (46%). Although patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p = 0.05).

Conclusion

Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, Black patients with Medicare or Medicaid insurance were less likely to complete video visits.

Impact of multidisciplinary patient education sessions on expectations and understanding of new calcitonin gene-related peptide treatments

Background: The new calcitonin gene-related peptide (CGRP) medications offer an exciting alternative to daily preventative migraine treatments. Finding effective and efficient ways to educate patients can be challenging for providers and pharmacists alike given the treatments are subcutaneous injections with extended half-lives and data is limited on long-term efficacy and adverse effects.

Aims: We aimed to develop and evaluate a patient-oriented, multidisciplinary presentation to inform patients about the new CGRP drug class to decrease provider and pharmacist education burden while increasing patient understanding.

Methods: Three live, one-hour CGRP informational sessions were conducted jointly by a headache medicine neurologist and clinical pharmacist from the institution’s specialty pharmacy. Prior to medication initiation, patients were educated about CGRP pathophysiology, benefits, risks, injection technique, and logistics of cost and medication access. The third presentation was video recorded and transitioned to an online platform. Participants completed surveys before and after watching the in-person or online session. Patients had the ability to fill these self-injectable therapies at the institution’s specialty pharmacy, who assisted with benefits investigation and prior authorization. If within payor network, the patient was offered specialty pharmacy services.

Results: A total of 84 patients participated in the session (41 in-person; 43 online). Patients had frequent headaches (mean = 18/month; SD = 9.2) with severe (MIDAS >21) headache-related disability (mean MIDAS score = 63.1). Participants reporting confidence in understanding CGRP significantly increased from 68% to 97% following the informational session (p < .001) for those completing both the pre- and post-survey question (n = 69). There was also a significant increase from 84% to 97% in participants reporting comfort with injection technique (p = .008, n = 70). For both measures, there was no statistically significant difference between the in-person and online sessions. Nearly all participants (97%) would recommend the session to family or friends with migraine.

Conclusions: The multidisciplinary informational session was an effective and efficient method of educating patients about these new treatments while concurrently decreasing provider and pharmacist education burden. The online video was as effective as the in-person session in educating patients, but improved access and availability.

Pearls & Oy-sters: The critical role of histopathology in diagnosing cancer-associated necrotizing CNS vasculitis

OBJECTIVE

To highlight the importance of a broad differential and histopathologic confirmation in patients with newly diagnosed cancer with brain lesions atypical for CNS metastasis.

METHODS

We report 2 cases of biopsy-proven CNS vasculitis in patients undergoing treatment for a newly diagnosed nonmetastatic cancer. Comprehensive medical record review was performed to identify the clinical presentation, representative neuroimaging, histopathologic features, and response to treatment.

RESULTS

Patient 1 presented 1 month into induction therapy of malignant vaginal squamous cell carcinoma (stage 3, T2N1M0) with acute episodic left-sided hemiparesis due to seizure activity progressing to severe encephalopathy. Imaging revealed a right frontoparietal lesion while systemic workup was unrevealing. Biopsy demonstrated necrotizing vasculitis. Patient 2 presented 6 months after diagnosis of right breast invasive ductal carcinoma (stage IIa, T2N0M0, estrogen receptor-positive, progesterone receptor-positive, human epidermal growth factor receptor-2 positive) with subacute bifrontal headaches with associated phonophobia. Imaging showed hyperintense lesions involving the right temporoparietal region and systemic workup was unrevealing. Brain biopsy showed a necrotizing vasculitis. Patient 1 was treated with methyprednisolone and plasmapheresis and patient 2 was treated with prednisone. Both patients showed complete resolution of symptoms shortly after treatment and improvement on imaging.

CONCLUSIONS

These cases highlight the importance of comprehensive evaluation of new brain lesions in patients with nonmetastatic solid tumors. Characteristics of new brain lesions in patients with cancer that should raise suspicion of diagnoses other than brain metastasis include (1) primary malignancy without regional or distant metastasis, (2) imaging without discrete mass-like enhancement, and (3) cortically based location of lesions not at the gray-white matter junction.

Assessment of two gait training models: conventional physical therapy and treadmill exercise, in terms of their effectiveness after stroke

BACKGROUND

Rehabilitation provided to patients after stroke mainly aims at improvement in gait function. The most common gait training strategies include treadmill exercise and traditional overground gait training. The study was designed to assess the effectiveness of two models of gait re-education in post-stroke patients, namely conventional physical therapy and treadmill training.

METHODS

A systematic literature review was performed, taking into account the online databases of Medline (PubMed), Science Direct, Web of Science, Google Scholar, and clinical trials registries. The following inclusion criteria were applied: studies published from 2008 to 2018, written in English, involving treatment and control groups, investigating conventional physical therapy and treadmill training administered for gait re-education after stroke.

RESULTS

Out of 160 articles identified, 23 met the inclusion criteria and were reviewed and analyzed. One hundred fifteen projects involving clinical trials were identified; out of these nine reports from the last five years are included in the review. The number of participants in all the studies totaled at 1,772. The participants in all the studies represented both sexes, and their age ranged from 18 to the late 80s, with an average of 60+ years of age. In most cases, the patients examined were at a chronic stage post-stroke, i.e., more than six months following stroke onset. The most frequently applied types of treadmill training included: high-intensity aerobic treadmill training and treadmill training with or without body weight support. Most interventions involved participation in 30- or 60-minute sessions, from three to five times weekly, for the duration of six to 16 weeks.

CONCLUSIONS

Treadmill training seems to be a valuable and effective method of gait re-education, which can be used at various periods following a stroke, and mainly leads to improvement in walking speed and walking capacity. However, no standard has been defined so far with regard to treadmill-supported recovery of gait function in patients after stroke. We still do not know the optimum duration and frequency of exercise. Further study should investigate long-term effects and the way treadmill training impacts on patients' daily activities. HIPPOKRATIA 2018, 22(2): 51-59.

Abstract TP398: Telestroke: Expanding the Utilization of Endovascular Treatment

Background: The Comprehensive Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. implemented a telestroke network system in January of 2010 to provide 24/7 access to one of their board certified vascular neurologists. There are presently fourteen hospitals in the network with over 1900 consults and a tPA administration rate of 42%.

In early 2015, positive results from four stroke interventional trials showed that recanalization rates were much higher after stent retrieval compared with tPA alone. It was shown that these devices can safely and effectively remove a blood clot that is causing a stroke, with improved clinical outcomes over IV tPA alone. Wake Forest Baptist has made the commitment to expand the use of intraarterial therapy to give every telestroke patient with a large vessel occlusion an opportunity to experience the outstanding clinical outcomes that have been seen in stroke patients treated at their medical center.

The following guidelines were developed to assist the network physician in determining when to consider interventional treatment:

- The time from onset is less than 6 hrs. (up to 12 hrs. in a suspected basilar artery stroke)

- A NIHSS score equal to or greater than 10 (indicating large vessel occlusion)

Method: Education was provided regarding the new interventional treatment guidelines and for quick reference, the protocol was placed on the screen of the telestroke robot/cart in each of the network hospitals and a cell phone number was provided that gave 24/7 access to communicate with the neurointerventionalist on call. A retrospective study was performed to determine if there had been an increase in patient transfers for an interventional procedure.

Results: In FY'14, 14 of 139 patients (10%) transferred received an IR procedure and in FY'15, 26 of 146 (17%) patients received an IR procedure. An increase of 7% was identified in telestroke patients that were transferred and underwent an interventional treatment. A combination of providing guidelines regarding when to consider interventional treatment as well as 24/7 access to a neurointerventionalist has significantly increased number of telestroke patients receiving interventional treatment.

Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature

BACKGROUND

The indications and contraindications for intravenous (IV) recombinant tissue plasminogen activator (rtPA) use in ischemic stroke can be confusing to the practicing neurologist. Here we seek to describe practice patterns regarding decision-making among US stroke clinicians.

METHODS

Stroke clinicians (attending and fellow) from the 8 National Institutes of Health SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) centers were asked to complete a survey ahead of the 2012 SPOTRIAS Investigators' meeting.

RESULTS

A total of 51 surveys were collected (71% response rate). Most of the responders were attending physicians (68%). Only 18% of clinicians reported strictly adhering to current American Heart Association guidelines for treatment within 3 hours from symptom onset; this increased to 51% for the European Cooperative Acute Stroke Study (ECASS) III criteria in the 3 to 4.5 hours time frame. All clinicians treat eligible patients in the 3 to 4.5 hours time frame. The great majority will recommend rtPA in the following scenarios: (1) elderly individuals irrespective of age (97%); (2) severe stroke irrespective of National Institutes of Health Stroke Scale (NIHSS) (95%); or (3) suspected stroke with seizures at symptom onset (91%). None recommended rtPA in the setting of an international normalized ratio >1.7. Most clinicians defined mild strokes as an exclusion based on the perceived disability of the deficit (80%) rather than on a specific NIHSS threshold.

CONCLUSIONS

Most surveyed stroke clinicians seem to find that the current IV rtPA eligibility criteria for the 3-hour time frame too restrictive. All would recommend rtPA to eligible patients in the 3 to 4.5 hours time frame despite the absence of an U.S. Food and Drug Administration (FDA)-approved indication.

Abstract TP69: Minimum NIHSS Score To Qualify For IV tPA

BACKGROUND: Frequently patients with ischemic stroke are excluded from IV tPA therapy because of mild deficits. Often a minimal score on the NIHSS is used to identify mild stroke patients, but some argue to specially weight motor and language deficits. We examined the outcomes of patients with Acute Ischemic Stroke (AIS) who did not receive IV tPA using four definitions of a “mild” deficit using the total and itemized NIHSS at baseline with the aim to identity patients with a mild deficit that highly predicts good outcome when not treated with thrombolysis. Additionally we examined if any single item on the NIHSS in mild stroke patients predict poor outcomes.

METHODS: We included all adult patients with mild (NIHSS 0-4) AIS from the UCSD SPOTRIAS Database from 2004-2012; excluded patients who received thrombolysis (IV or IA) or had a pre-stroke mRS >0. We analyzed baseline demographics (age, sex, race, HTN, DM, afib), total NIHSS, NIHSS items (normal or abnormal) and 90-day mRS. We evaluated four definitions of mild deficits: 1) total NIHSS 0-4; 2) NIHSS 0-4 AND arm (Q5) AND leg weakness (Q6) 0-1, AND aphasia (Q9) 0-1; 3) NIHSS 0-4 AND Q5,6,9=0; 4) NIHSS 0-4 AND Q5+6+9<2. Good outcome was defined as 90-day mRS 0-1.

RESULTS: A total of 147 patients were included (definition #1), under mild #2 we identified 111, #3 78 and #4 106 patients. Good outcome was achieved in 70.8%, 70.3, 74.4% and 70.8% of each definition. No NIHSS item (0 vs >0) correlated with poor outcome in mild patients.

CONCLUSION: We found no significant difference in outcome prediction when weighing motor and language deficit over the overall NIHSS <5. In the patients with mild stroke, no specific NIHSS scoring item predicted poor outcome.

Abstract TP371: Does Symptom Onset to Primary Stroke Center Time Points Affect Stroke Outcome?

Background: Treating acute ischemic stroke (AIS) within 4.5 hours, and with door to needle time of <60min may optimize recovery. It is unknown if onset to PSC time goals is a predictor of outcome. The purpose of this study was to examine effects of symptom onset to PSC time goals on recovery.

Methods: A retrospective analysis of prospectively collected UCSD SPOTRIAS data was performed. IV rtPA AIS patients were included if they were treated within 270 minutes, and had known 90 day mRS. In-hospital strokes were excluded. Primary outcome was good 90 day mRS(0-2) as predicted by: onset to needle, onset to imaging, onset to stroke code, onset to neuro exam, onset to labs, and onset to decision. Logistic regression was performed (categorized by quartiles).

Results: 291 patients were included (49.8% female, mean age 70.6, median NIHSS 10). Group differences included: HTN (p=0.0002), A.fib (p=0.0005), pre-stroke mRS (p<0.0001), and ethnicity (p =0.0112). Good outcome occurred in 45.0%. Comparing good to poor outcome groups: Mean onset to arrival was 70.6min vs. 62.5min (p=0.13). Mean onset to needle was 140.1min vs. 134.9min (p=0.18). There were no differences in other onset to time goals. Controlling for pre-specified covariates and multiple comparisons, onset to arrival (F-test p=0.09), onset to needle time (F-test unadj p=0.06), onset to stroke code (F-test unadj p=0.20), onset to neuro exam (F-test unadj p=0.28), onset to imaging (F-test unadj p=0.11), onset to lab (F-test unadj p=0.86), and onset to decision (F-test p=0.045) were not significant predictors of 90 day outcome.

Conclusions: In an academic center providing comprehensive stroke services, onset to time goals was not a significant predictor of 90 day outcome. Expedited care processes in comprehensive stroke centers may compensate for differences in outcomes based on onset time. These results should be validated in a larger cohort in PSCs vs. CSCs.

Patient management problem-preferred responses

Following are the preferred responses for the Patient Management Problem in this CONTINUUM issue. The case, questions, and answer options are repeated, and the preferred response appears in bold print, followed by an explanation and a reference with which you may seek more specific information. You are encouraged to review the responses and explanations carefully to evaluate your general understanding of the material. The comment and references included with each question are intended to encourage independent study.

Workers' compensation, FMLA, and ADA. Managing the maze

The interrelationship of WC, FMLA, and ADA can present challenges to the employer in relation to liability and compliance. Successful management of WC, FMLA, and ADA in the workplace encompasses a holistic model of disability management. The nurse's role presents an opportunity to centralize the management of WC, FMLA, and ADA to assure compliance, fairness, and consistency in benefit application.