Virtual House Calls Favored for Parkinson's Care

Nancy A. Melville

August 22, 2017

Patients with Parkinson's disease (PD) who receive specialist care via virtual house calls using video conferencing report satisfaction and preference for these types of visits over traditional in-office care, with a significant benefit of reduced time and burden of traveling to receive in-office care, results of a randomized trial suggest.

"The study demonstrated that virtual visits were well received by specialists and patients, increased access in underserved areas, and, in the end, were preferred by patients to traditional visits on all metrics measured," senior author, E. Ray Dorsey, MD, University of Rochester Medical Center in New York, told Medscape Medical News.

The study was published online August 16 in Neurology.

First Study of Its Kind

Investigators report that this is the first randomized, controlled trial of its kind. The 1-year study included 195 patients with PD (mean age, 66 years) who were randomly assigned 1:1 to virtual visits from a neurologist (n = 97) or continuation of their usual care (n = 98).

The virtual visit format generally included taking a medical history and performing a PD–specific examination, including assessment of tremor and gait, time to address patients' concerns, and providing recommendations, through in-home video conferencing.

Most patients in the intervention group (98%) completed at least one virtual visit and 91% of the virtual visits were completed.

The primary outcome measure of change in quality of life according to change on the 100-point Parkinson's Disease Questionnaire-39 scale did not significantly differ between the virtual house call and usual care groups (mean change, –0.4 and –0.8, respectively; P = .78). Measures of quality of care and caregiver burden also showed no difference.

The lack of improvement in quality of life in the virtual care group may have been the result of various factors, including that 73% of patients had met with a PD specialist in the past year and 83% indicated that they were satisfied with their care, the authors note.

"The absence of improvement in quality of life from the addition of virtual visits in this study could be due to several factors, including the possibility that virtual visits with a specialist are insufficient to improve quality of life," they write.

The findings nevertheless support the feasibility and safety of the virtual visit approach, with improvements seen in a variety of other measures. For instance, virtual house calls had the benefit of sparing patients a median of 88 minutes (P < .0001) and an average of 169 miles of travel per visit (P < .0001).

Acceptance of the virtual visit approach was meanwhile high, with 97% of patients and 85% of neurologists reporting satisfaction with the virtual visits and 55% of patients reporting that they preferred virtual visits over in-person visits.

"At the study's end, participants preferred virtual visits with their remote specialist to their usual in-person PD clinician on all aspects measures," the authors report.

Evidence of patient satisfaction is reflected in the high rate of completed virtual visits, which even exceeds some reports that include no-show rates in traditional visits, the investigators note.  

"The proportion of visits completed (over 90%) is in line with the proportion of in-person clinic visits completed in an earlier pilot study and on par with, if not better than, many published studies of no-show rates for traditional in-person clinic appointments."

Results Generalizable?

An important limitation of the study was that participants were largely white, had high levels of education, and were familiar with the Internet.

"The study results thus may not be generalizable to the broader community of individuals with PD," the authors write.

Failure to receive care from a neurologist is linked to increased morbidity and even premature mortality in PD, yet more than 40% of patients with the condition never receive such care, underscoring the need to reach out to patients with virtual house calls to their homes, the authors say.

A key barrier in providing virtual house calls, however, is that coverage by Medicare is limited. Telemedicine visits are currently only covered for patients who reside in rural areas, and providers must be licensed in the state where the patient resides.

Even then, the coverage is only for cases of patients receiving an exam in a clinic or hospital, where the patient is presented by the clinical staff to the remote clinician.

Telehealth in fact represented less than 0.01% of Medicare's budget in 2015, the authors noted, whereas increasing coverage by other agencies and private insurers shows acceptance and acknowledgment of the potentially substantial benefits of providing virtual care in the home.

"Extending Medicare's telehealth coverage to the home and to all beneficiaries, regardless of geography, would mirror other federal (e.g., Veterans' Administration) and private (e.g., Kaiser Permanente of Northern California) payers," the authors note.

A Good Fit

PD, in particular, lends itself to management through virtual exams for many reasons, such as the need to adjust medications according to patient needs, said David R. Shprecher, DO, from Banner Sun Health Research Institute in Sun City, Arizona.

"The medications need to be adjusted carefully to ensure the right balance between symptom control and side effects. Furthermore, the wide array of motor and nonmotor symptoms cannot always be addressed simultaneously in one visit," Dr. Shprecher told Medscape Medical News.

He added that "virtual exams and counseling would allow more individuals with Parkinson's disease, who would be otherwise unable or subject to undue travel burden, to see a specialist regularly."

Many, if not most, elements of an exam could be accomplished in a virtual exam, said Dr Shprecher, coauthor of an accompanying editorial along with Jennifer J. Majersik, MD, from Vascular Neurology Division, University of Utah, Salt Lake City.

"With the exception of muscle tone and postural reflexes, all other aspects of the motor exam relevant to Parkinson's disease can be completed remotely through a virtual house call," he said.

Dr Shprecher noted that his own center, Banner Health, has had success with virtual house calls in various types of cases.

"Banner Health has shown that virtual house calls can reduce cost of care for individuals with multiple chronic illnesses, including heart disease and diabetes, in a managed care plan. An important next step will be to study the potential of the virtual house call to improve quality of life, and reduce cost of care for, patients with chronic neurodegenerative diseases," he said.

Broader Acceptance Needed

Samuel Frank, MD, associate professor of neurology at Harvard Medical School and director of the Huntington's Disease Society of America Center of Excellence at Beth Israel Deaconess Medical Center, Boston, Massachusetts, added that plenty of examples from other specialties underscore that the time has come for broader acceptance of the practice.
"Overall, this same technology is used for social and work communication purposes all the time, every day around the world. It only makes sense to start incorporating it into medical practice," he told Medscape Medical News.

"More homes across the US are fitted with high-speed Internet, and more patients of all ages are becoming connected through email, social networking, and portals with their health providers," he said.  

"This study further supports the use of digital media as a supplement and in some cases a replacement for time-consuming in-person visits."

For patients with Parkinson’s disease, virtual house calls can in some cases improve upon office visits by giving a more accurate assessment of patients at home, Dr Frank added.

"Particularly for Parkinson’s disease, travel and getting into a doctor’s office may be enough of a burden that we do not assess patients in a natural state," he said.

"Virtual house calls may be limiting in some respects with the exam, but most of the necessary aspects of the exam are available."

The study was funded by the Patient-Centered Outcomes Research Institute. Dr Dorsey is on the medical advisory board of and has stock options in Grand Rounds. Dr Shprecher has received research support from the Arizona Alzheimer's Consortium, Axovant, Biotie, Intec, Teva, US World Meds, Michael J. Fox Foundation, Neurocrine, and National Institutes of Health; consultant fees from Eli Lilly, Teva, Lundbeck, and Weston Brain Institute; and honoraria from Acadia, Arizona Psychiatric Society, Baylor College of Medicine, Lundbeck, and Tourette Association of America.

Neurology. Published August 16, 2017. Abstract, Editorial

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