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Store-and-forward teleneurology results in a large Brazilian city

Telerregulação em neurologia e seus resultados em uma grande cidade brasileira

Abstract

Background

Neurology is a high-demand specialty with long waiting lines. Some pathologies require rapid decision-making. Through technology, telemedicine can allow neurological patients to have faster access to specialized assessment. In store-and-forward telemedicine, the specialist physician evaluates data collected by a general practitioner and optimizes screening.

Objective

The aim of the present study is to evaluate the effectiveness of asynchronous telemedicine, used to refer patients from primary care to neurology, in the city of Curitiba, in southern Brazil.

Methods

A retrospective analysis of all patients referred from primary care to neurology between September 2019 and February 2020. After a request is made by a general medical doctor for a specialist's opinion, 5 neurologists with complete access to patients' records are tasked with the decision-making. The main variables analyzed were clinical reasons for telemedicine request, neurologist decision, final diagnosis, indication for diagnostic procedures, and subsequent follow-up.

Results

Between September 2019 and February 2020, 1,035 asynchronous telemedicine consultations were performed. Headache (30.43%), epilepsy (19.03%), and dementia (15.85%) accounted for almost two-thirds of the primary care requests; one-third of the cases (33.62%) required a complementary diagnostic procedure. More than 70% of the cases did not require face-to-face assessment by a neurologist.

Conclusions

In this study, store-and-forward teleneurology successfully reduced the need for in-visit consultation in 70% of cases. Further studies should identify the best opportunities for teleneurology in the city of Curitiba to facilitate better integrated care between primary care providers and neurologists.

Keywords
Neurology; Telemedicine; Primary Health Care; Telerregulation

Resumo

Antecedentes

Neurologia é uma especialidade de alta demanda com grandes filas de espera. Algumas doenças necessitam de rapidez na tomada de decisões. A telemedicina permite que pacientes neurológicos tenham acesso mais rápido à avaliação especializada. Na telerregulação, um ramo da telemedicina, o especialista avalia os dados coletados pelo generalista e otimiza a triagem.

Objetivo

Avaliar a eficácia da telerregulação assíncrona, usada para referenciar pacientes da atenção primária à neurologia, na cidade de Curitiba, no sul do Brasil.

Métodos

Análise retrospectiva de todos os pacientes referenciados da atenção primária para a especialidade de neurologia, no período entre setembro de 2019 e fevereiro de 2020, em Curitiba, Brasil. Para cada pedido de avaliação do médico generalista, 5 neurologistas experientes tiveram acesso completo ao prontuário para a tomada de decisão. As variáveis analisadas foram: razões para o referenciamento, decisão do especialista, diagnóstico final, indicação de exame complementar e necessidade de acompanhamento com a especialidade.

Resultados

Durante o período de estudo, 1.035 telerregulações foram realizadas. Cefaleia (30.43%), epilepsia (19.03%) e demência (15.85%) compreenderam aproximadamente dois terços de todos os pedidos de consulta; para um terço dos casos, o especialista indicou exame complementar. Mais de 70% dos pacientes não necessitaram de consulta presencial com neurologista.

Conclusões

A telerregulação assíncrona diminuiu de forma importante a necessidade de avaliação presencial pelo neurologista em 70% dos casos. Através da tecnologia, é possível conseguir melhor integração entre atenção primária e serviços especializados. Ainda são necessários mais estudos para explorar as janelas de oportunidade para a teleneurologia no Brasil.

Palavras-chave
Neurologia; Telemedicina; Atenção Primária à Saúde; Telerregulação

INTRODUCTION

The world's population is aging. The increase in the number of elderly people is accompanied by an increase in the number of patients affected by neurological diseases.11 World Health Organization. Neurological disorders: public health challenges. World Health Organization; 2006,22 Dall TM, Storm MV, Chakrabarti R, et al. Supply and demand analysis of the current and future US neurology workforce. Neurology 2013;81(05):470-478 In contrast, some countries have observed a reduction in the number of neurology specialists in recent years, producing a gap between the epidemiological impact and the specialty capacity.33 Hatcher-Martin JM, Adams JL, Anderson ER, et al. Telemedicine in neurology. Neurology 2020;94(01):30-38,44 American Association of Telemedicine. What is telemedicine and telehealth? Accessed 06/30/2017 at http://www.americantelemed.org/files/public/abouttelemedicine/whatistelemedicine.pdf
http://www.americantelemed.org/files/pub...
To reduce this gap, some opportunities have been developed, such as telemedicine.

Telemedicine (TM) is defined as medical practice at a distance, or not in person, using modern communications technology.55 Wechsler LR, Tsao JW, Levine SR, et al; American Academy of Neurology Telemedicine Work Group. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology 2013;80(07):670-676. Doi: 10.1212/wnl.0b013e3182823361
https://doi.org/10.1212/wnl.0b013e318282...
It can be synchronous, through real-time video communication, or asynchronous. Asynchronous telemedicine refers to store-and-forward consultation between healthcare professionals as a form of triage or for definitive diagnosis and management.66 Mechanic OJ, Persaud Y, Kimball AB. Telehealth Systems. 2021 Sep 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2021 Jan-. PMID: 29083614. Teleneurology is an emergent branch of TM. Although neurological conditions commonly require a complex physical examination, the patient history is sufficient to improve triage referrals.77 Teleneurology PV. J Telemed Telecare 2005;11:55-59

The aim of the current study is to evaluate the effectiveness of asynchronous TM for patient referral from primary care to a neurology specialist in Curitiba.

METHODS

The study is a retrospective analysis of all patients referred from primary care to neurology, between September 2019 and February 2020, in a tertiary hospital. The study was approved by the Ethical Committee of the Hospital das Clínicas of the Federal University of Paraná, and the board waived the need for patient consent. Each teleneurology session comprised an asynchronous evaluation, by a trained neurologist, of patients' records in primary care in the city of Curitiba in Southern Brazil.

The inclusion criteria were: 1) patients from Curitiba with a primary care evaluation in any primary healthcare center, 2) complete information available on the patient, and 3) the patient's last consultation within the last 4 months. Meanwhile, the exclusion criteria were: 1) duplicate consultations with the same patient, 2) citizens outside of Curitiba, 3) clinical information not available or not enough to make a decision.

All patients were placed in the store-and-forward system by a general medical doctor from the primary healthcare system of the city of Curitiba; 5 neurologists with at least 5 years of specialty experience were educated and trained to communicate with other physicians and provide useful consultations. Each neurologist had complete access to the patients' records for the decision-making process. Each patient record was evaluated by one of the five neurologists. When a patient's complaint was related to a neurology subspecialty, this specialist oversaw the final management.

The following variables were considered: sex; age in years; specific clinical reason for enrollment into TM; general clinical reason for enrollment into TM (diagnosis, management); the TM decision (i.e., if more data are required); diagnosis from the TM appointment; subsequent follow-up (the decision to keep patients in primary care or if in-person evaluations are required); and indications for diagnostic procedures. For the patients that remained in primary care, neurologists guided the primary care providers regarding diagnosis and management, including therapeutic options, drug titration, and drug monitoring with laboratory tests.

After data collection, a descriptive analysis of the variables was conducted. Quantitative variables are presented as means and standard deviations (SD) or by median, minimum, and maximum values according to their adherence to normal distribution. Categorical variables are presented as frequencies and percentages.

RESULTS

Between September 2019 and February 2020, 1,035 consultations were performed. The mean age was 49.98 ± 19.63 years, and 584 (56.43%) of the total number of patients were women. In 11 (1.06%) patients, the sex was not communicated.

When considering the general clinical reasons for TM request, 322 (31.11%) were for diagnosis, 336 (32.46%) were for therapeutic reasons or for the management of current conditions, 236 (13.14%) were diagnostic procedure requests (i.e., electroneuromyography), 100 (9.66%) were intended for other specialties, 49 (4.73%) were for answers to a previous consultation, 16 (1.55%) were for judicial demand, and 271 (26.18%) were for other reasons. Furthermore, 195 (18.84%) patients had more than one general clinical reason for participating in TM.

When considering the specific clinical reason for the TM request, headache was the main complaint presented in 315 (30.43%) patients. This was followed by epilepsy in 197 (19.03%), dementia in 164 (15.85%), neuromuscular disorders in 107 (10.34%), cerebrovascular diseases in 110 (10.63%), vestibular/dizziness in 101 (9.76%), and movement disorders in 80 (7.73%) patients. Other complaints were observed in 176 patients (17.00%); 237 patients (22.90%) had more than one complaint based on the primary care evaluation.

Based on the primary care information, more data were needed in 427 (41.26%) requests before a full decision could be made. When considering the final decision, follow-up in primary care was recommended for 713 (68.89%) patients, 298 (28.79%) patients were sent to face-to-face neurological evaluation, and only guidance was required for 24 (2.32%) patients. Additionally, for 64 (6.18%) patients, the TM session led to the decision to send them to a specified center.

During the process, 348 (33.62%) patients received complementary examinations. More than one test was suggested for 125 patients (12.08%). Finally, a computed tomography (CT) was required for 156 (44.83%) patients; magnetic resonance imaging (MRI) for 113 (32.47%); electroencephalography (EEG) for 48 (4.64%); vascular imaging, such as angiotomography or magnetic resonance angiography, for 38 (10.92%); echocardiography and carotid Doppler for 30 (8.62%); electromyoneurography (EMNG) for 6 (1.72%); and common laboratory tests for 4 (1.15%) (Table 1).

Table 1
Descriptive analysis of 1,035 patients referred from primary care to neurology in Curitiba – Brazil

DISCUSSION

The current study demonstrated that store-and-forward teleneurology reduced the need for in-person neurological evaluations in more than 70% of cases. Headache, epilepsy, and dementia represented almost two-thirds of primary care requests, and one-third of cases required a complementary diagnostic procedure.

Compared with previous studies, there was a similar predominance of women, who were approximately 50 years of age.88 Bradi AC, Sitwell L, Liddy C, Afkham A, Keely E. Ask a neurologist: What primary care providers ask, and reducing referrals through eConsults. Neurol Clin Pract 2018;8(03):186-191. Doi: 10.1212/cpj.0000000000000458
https://doi.org/10.1212/cpj.000000000000...
The most common requests were for diagnosis and management, comprising 63% of cases, which is a lower number than that of a recent study where these requests represented more than 80% of the demands.88 Bradi AC, Sitwell L, Liddy C, Afkham A, Keely E. Ask a neurologist: What primary care providers ask, and reducing referrals through eConsults. Neurol Clin Pract 2018;8(03):186-191. Doi: 10.1212/cpj.0000000000000458
https://doi.org/10.1212/cpj.000000000000...
Probably, a higher stratification for these criteria was presented in the current study. In Curitiba, primary care providers are not allowed to directly demand some complementary tests (13% of the consultations). Additionally, other specialists cannot directly request neurological evaluations without primary care connection.

Headache, epilepsy, dementia, neuromuscular disorders, and cerebrovascular disease were the 5 main complaints of the current study. However, in other countries studies, imaging findings, tingling/numbness, multiple sclerosis, and paresthesia were in the top requests.88 Bradi AC, Sitwell L, Liddy C, Afkham A, Keely E. Ask a neurologist: What primary care providers ask, and reducing referrals through eConsults. Neurol Clin Pract 2018;8(03):186-191. Doi: 10.1212/cpj.0000000000000458
https://doi.org/10.1212/cpj.000000000000...
,99 Williams L, O’Riordan S, McGuigan C, Hutchinson M, Tubridy N. A web-based electronic neurology referral system: a solution for an overburdened healthcare system? Ir Med J 2012;105(09): 301-303 A possible explanation for this is that primary headaches are not properly diagnosed and managed in Brazil due to the lack of public policies addressing this problem.1010 Peres MFP, Oliveira AB, Sarmento EM, et al. Public policies in headache disorders: needs and possibilities. Arq Neuropsiquiatr 2020;78(01):50-52 A recent review suggested that teleconsultations should be encouraged in the care of these patients.1111 Domingues RB, Mantese CE, Aquino EDS, Fantini FGMM, Prado GFD, Nitrini R. Telemedicine in neurology: current evidence. Arq Neuropsiquiatr 2020;78(12):818-826

In 41% of the TM appointments, the neurologist had to request more information. We postulate that this can delay the specialist's final decisions. When a request is incomplete, the neurologist will review it more than once, possibly delaying the decisions of other patients. If the case report was complete, with all the necessary information for referral and description of the neurological condition, the neurologist would spend less time analyzing each patient.

The rate of reduction in the need for in-person consultations reaffirms the need for improving the teleneurology system. More than 70% of the cases did not require face-to-face assessment by a neurologist. In the current study, almost 70% of patients remained in primary care and 298 patients (28.79%) were sent for presential neurological evaluation.

Improving the telehealth system has the potential to reduce waiting lines, as demonstrated by a study conducted in Rio Grande do Sul, in Southern Brazil. In this study, the implementation of protocols of telemedicine achieved a general reduction in the queue volume for specialized consultation by approximately 30%.1212 Katz N, Roman R, Rados DV, et al. Acesso e regulação ao cuidado especializado no Rio Grande do Sul: a estratégia RegulaSUS do TelessaúdeRS-UFRGS. Cien Saude Colet 2020;25(04):1389-1400 Besides reducing waiting lines, neurological patients may have functional incapacity. Therefore, instead of bringing a sick patient to see a doctor, teleconsultation allows neurological care to reach this patient, thereby overcoming functional distance. In this scenario, teleneurology has emerged as a useful tool for better diagnosis and patient care.1313 Müller KI, Alstadhaug KB, Bekkelund SI. A randomized trial of telemedicine efficacy and safety for nonacute headaches. Neurology 2017;89(02):153-162

Some limitations were present in the current study. First, this was a single-center retrospective analysis. Furthermore, in 41% of the cases, the neurologist requested more information, and this number was higher than expected. For better communication, our local system needs appropriate training for primary care providers, and sufficient monitoring of processes and outcomes. As an initial analysis, we still have no data regarding patient outcomes, such as reduction in hospitalization or mortality.

Nevertheless, this study provides important insights for our local healthcare system. In Brazil, the long wait to see a specialist is one of the main reasons for dissatisfaction referred by public Unified Health System users.1414 DATASUS. Opinião do brasileiros sobre o atendimento na área de saúde. Accessed 26/02/2021 at https://portal.cfm.org.br/images/PDF/apresentao-integra-datafolha203.pdf
https://portal.cfm.org.br/images/PDF/apr...
According to the Curitiba municipal health secretary, the median waiting time for a specialist consultation is 10 months.1515 Curitiba municipal health secretary. Saúde Já vai diminuir espera por exames e as filas de consultas de especialidades. Accessed 26/02/2021 at https://saude.curitiba.pr.gov.br/noticias/23-noticias-principal/618-saude-ja-vai-diminuir-espera-por-exames-eas-filas-de-consultas-de-especialidades
https://saude.curitiba.pr.gov.br/noticia...

In conclusion, the current study demonstrated that store-and-forward teleneurology achieved a 70% reduction in the intended consultation for neurology specialists. Further studies are needed to evaluate the effects of teleneurology in the city of Curitiba. We see this as a window of opportunity for structural reforms and better integrated care, particularly for those with neurological conditions.

References

  • 1
    World Health Organization. Neurological disorders: public health challenges. World Health Organization; 2006
  • 2
    Dall TM, Storm MV, Chakrabarti R, et al. Supply and demand analysis of the current and future US neurology workforce. Neurology 2013;81(05):470-478
  • 3
    Hatcher-Martin JM, Adams JL, Anderson ER, et al. Telemedicine in neurology. Neurology 2020;94(01):30-38
  • 4
    American Association of Telemedicine. What is telemedicine and telehealth? Accessed 06/30/2017 at http://www.americantelemed.org/files/public/abouttelemedicine/whatistelemedicine.pdf
    » http://www.americantelemed.org/files/public/abouttelemedicine/whatistelemedicine.pdf
  • 5
    Wechsler LR, Tsao JW, Levine SR, et al; American Academy of Neurology Telemedicine Work Group. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology 2013;80(07):670-676. Doi: 10.1212/wnl.0b013e3182823361
    » https://doi.org/10.1212/wnl.0b013e3182823361
  • 6
    Mechanic OJ, Persaud Y, Kimball AB. Telehealth Systems. 2021 Sep 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2021 Jan-. PMID: 29083614.
  • 7
    Teleneurology PV. J Telemed Telecare 2005;11:55-59
  • 8
    Bradi AC, Sitwell L, Liddy C, Afkham A, Keely E. Ask a neurologist: What primary care providers ask, and reducing referrals through eConsults. Neurol Clin Pract 2018;8(03):186-191. Doi: 10.1212/cpj.0000000000000458
    » https://doi.org/10.1212/cpj.0000000000000458
  • 9
    Williams L, O’Riordan S, McGuigan C, Hutchinson M, Tubridy N. A web-based electronic neurology referral system: a solution for an overburdened healthcare system? Ir Med J 2012;105(09): 301-303
  • 10
    Peres MFP, Oliveira AB, Sarmento EM, et al. Public policies in headache disorders: needs and possibilities. Arq Neuropsiquiatr 2020;78(01):50-52
  • 11
    Domingues RB, Mantese CE, Aquino EDS, Fantini FGMM, Prado GFD, Nitrini R. Telemedicine in neurology: current evidence. Arq Neuropsiquiatr 2020;78(12):818-826
  • 12
    Katz N, Roman R, Rados DV, et al. Acesso e regulação ao cuidado especializado no Rio Grande do Sul: a estratégia RegulaSUS do TelessaúdeRS-UFRGS. Cien Saude Colet 2020;25(04):1389-1400
  • 13
    Müller KI, Alstadhaug KB, Bekkelund SI. A randomized trial of telemedicine efficacy and safety for nonacute headaches. Neurology 2017;89(02):153-162
  • 14
    DATASUS. Opinião do brasileiros sobre o atendimento na área de saúde. Accessed 26/02/2021 at https://portal.cfm.org.br/images/PDF/apresentao-integra-datafolha203.pdf
    » https://portal.cfm.org.br/images/PDF/apresentao-integra-datafolha203.pdf
  • 15
    Curitiba municipal health secretary. Saúde Já vai diminuir espera por exames e as filas de consultas de especialidades. Accessed 26/02/2021 at https://saude.curitiba.pr.gov.br/noticias/23-noticias-principal/618-saude-ja-vai-diminuir-espera-por-exames-eas-filas-de-consultas-de-especialidades
    » https://saude.curitiba.pr.gov.br/noticias/23-noticias-principal/618-saude-ja-vai-diminuir-espera-por-exames-eas-filas-de-consultas-de-especialidades

Publication Dates

  • Publication in this collection
    21 Nov 2022
  • Date of issue
    Aug 2022

History

  • Received
    19 Oct 2021
  • Accepted
    20 Dec 2021
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