AAN Makes a Call on Telemedicine Across Neurology

Telemedicine can be appropriate for evaluating patients who experience a concussion, traumatic brain injury (TBI), or headache, as well as for assessing many patients who live with epilepsy, dementia or movement disorders, a new study from the American Academy of Neurology (AAN) suggests.

"The results of the American Academy of Neurology's review show that a diagnosis from a neurologist by video for certain neurologic conditions is likely to be as accurate as an in-person visit," lead author Jaime Hatcher-Martin, MD, PhD, who was with Emory University in Atlanta, Georgia, while serving on the AAN's Telemedicine Work Group, and is now with the company SOC Telemed, told Medscape Medical News.

"Telemedicine can be especially helpful for people with epilepsy, who may not be able to drive to appointments, people with neurologic disorders like multiple sclerosis and movement disorders, who may have mobility issues that make getting to a clinic difficult, and for people in rural areas who may not be able to see a neurologist who is located in a city many hours away," said Hatcher-Martin, who is also a member of the AAN.

In addition, telemedicine could allow neurologists who would otherwise choose to work part-time or stop practicing altogether because of various social, physical, and health factors to continue to practice full-time, the authors note.

The study was published online December 4 in Neurology.

The aim of the literature review by the 21 members of the AAN Telemedicine Work Group was to gather evidence to guide neurologists considering adding or expanding telemedicine services.

However, the group discovered insufficient research to conduct a full systematic review. Therefore, they caution that few randomized controlled trials evaluate teleneurology outside of stroke, and the findings are not to be construed as expert consensus or official guidelines.

Even so, they found evidence supporting the noninferiority of telemedicine and data suggesting patients can be just as satisfied compared with in-person consultations.

The experts assessed 101 studies on telemedicine in the following eight areas.

Concussion and TBI

Data addressing concussions and TBI are limited, although investigators are starting to evaluate use of video consults for these conditions, including remote return-to-play evaluations for concussion management, the researchers found.

Telemedicine could address an unmet need, they add. There is a "dearth of physicians" to evaluate people with these common injuries, particularly in rural areas, and military settings often lack concussion diagnosis support.

Dementia

Dementia is "quite amenable" to remote evaluation, the authors note, because patient interviews comprise a large portion of the examination for this condition.

"Current studies in teleneurology for dementia care suggest increased access, good diagnostic accuracy, patient and provider satisfaction, and possible cost savings," they add.

Multiple studies also point to an overall comparable diagnostic accuracy between telemedicine and in-person assessment, including use of brief clinical assessment measures.

Epilepsy

"Ample evidence in the literature supports the successful use of teleneurology for people with epilepsy," the authors note.

Unique challenges, such as restricted driving privileges, can be addressed through video consultation. In addition, long-term management can be facilitated by telemedicine, they add, because follow-up outpatient epilepsy visits often focus less on physical examination and more on adherence, antiepileptic drug side effects, and counseling.

Headache

Like the shortage of concussion and TBI experts in some areas, the authors point to a "dearth of headache specialists" for fueling interest in teleneurology in this clinical area.

Despite evidence pointing to noninferiority and greater convenience, the current evidence is flawed, they add. Prior research was conducted in artificial settings, did not include full neurologic evaluations or included only a small number of participants, for example.

Future studies of telemedicine across multiple types of headache are warranted.

Movement Disorders

Telemedicine could potentially improve access to experts in movement disorders. The technology also could facilitate earlier diagnoses, access to specialty care, and the diagnosis and management of any cognitive impairment or psychiatric comorbidities.

"While there was generally wide acceptance across many of the studies," they add, "there were reports of time requirements and ineffective evaluations of children with complex movement and postural disorders due to poor video quality."

Multiple Sclerosis

Travel to specialty centers for MS care can become increasingly difficult if disability progresses. This can make telemedicine "an attractive option," the authors note.

The evidence suggests provider and patient satisfaction was high with both in-home and teleneurology for cognitive testing, health promotion, and home-based management. In contrast, a Cochrane Review found low-level evidence for telerehabilitation to improve disability, fatigue, and quality of life.

Neuromuscular Disorders

Although patients with stable neuromuscular disorder symptoms could benefit from a telemedicine evaluation, the evidence is less convincing here, the authors note.

Neuromuscular disorders range from common presentations like diabetic neuropathy to rare conditions like periodic paralysis, the authors note, making a judgment call on telemedicine more challenging.

"While there is rapid advancement in diagnostic technology, diagnosing many of these conditions requires detailed neurologic examinations to identify subtle findings that may not be easily appreciated during examinations through teleneurology," they add.

Inpatient General Neurology

Evidence for telemedicine for inpatient general neurology is limited.

However, one study linked teleneurology to significantly shorter stays without any difference in diagnosis, mortality, or use of inpatient hospital resources or medical services in the follow-up period compared with patients in a hospital that did not use remote video consultations.

Clinical Messages

Teleneurology can allow earlier access to specialized care, reduce patient and caregiver burden, and improve patient satisfaction across a range of neurologic conditions, the researchers note.

However, Hatcher-Martin said, "Telemedicine cannot completely replace in-person care. Telemedicine is not ideal for evaluating all neurological issues such as subtle differences in muscle strength or sensation, reflexes, or complex eye movements or vestibular abnormalities," she added. "Unless there is a trained telepresenter that can evaluate these issues on the neurologists' behalf, these issues are better suited for a detailed bedside exam."

The technology should be considered "a tool that can expand a practice's reach and potentially improve follow-up rates," she said. "Many patients may see this option as a bonus and choose a practice with this kind of flexibility."

In terms of practical considerations, anyone considering incorporating telemedicine into their practice needs to be cognizant of their specific state laws, that the physician needs to be licensed in the state where the patient is located, and the requirements for reimbursement by the various payers and insurance companies, Hatcher-Martin said.

The AAN's Practice Management & Technology subcommittee plans to continue evaluating the use of telemedicine in neurology.

"This is just the beginning of evaluating the benefits of telemedicine in neurology," senior author Raghav Govindarajan, MD, FAAN, of the University of Missouri, Columbia, who served as chair of the AAN Working Group, stated in a news release.

"We need to conduct further studies to better understand when virtual appointments are a good option for a patient," Govindarajan added.

Evolving Field

This review is "an important exploration into an evolving field," Amy K. Guzik, MD, and Jeffrey A. Switzer, DO, write in an accompanying editorial.

"There is emerging evidence on the utility of telemedicine in expediting care, increasing access, reducing cost, and improving health outcomes, although studies are limited and inconsistent," write Guzik, who is affiliated with Wake Forest School of Medicine in Winston-Salem, North Carolina, and Switzer, who is with Augusta University in Georgia.

"We see that the scope and quality of research are much greater in specialties such as movement disorders, while there is opportunity for further evaluation of teleneurology in other specialties such as headache and neuromuscular disease."

"Although adoption [of teleneurology] may be driven by convenience and cost savings, for care as effective as in-person visits, we need further data on clinical outcomes," they add.

Neurol. Published online December 4, 2019. Abstract, Editorial

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