Keywords
Neurology - Telemedicine - Primary Health Care - Telerregulation
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.[1]
[2] 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.[3]
[4] 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.[5] 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.[6] 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.[7]
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
|
n = 1,035
|
%
|
|
Population characteristics
|
Women
|
584
|
56.43
|
|
Men
|
440
|
42.51
|
|
No defined
|
11
|
1.06
|
|
Age (mean ± SD)
|
49.98
|
19.64
|
|
Teleregulation indication
|
Diagnosis
|
322
|
31.11
|
|
Therapeutics and management
|
336
|
32.46
|
|
Request of diagnostic procedure
|
236
|
13.14
|
|
Other specialty
|
100
|
9.66
|
|
Judicial demand
|
16
|
1.55
|
|
Other
|
271
|
26.18
|
|
More than one question
|
195
|
18.84
|
|
Not defined
|
29
|
2.80
|
|
Review of previous TR
|
49
|
4.73
|
|
Additional request
|
More clinical data from primary care
|
427
|
41.26
|
|
Final decision
|
Maintain in primary care
|
713
|
68.89
|
|
Indication of diagnostic test by neurologist
|
348
|
33.62
|
|
Send to neurological evaluation
|
298
|
28.79
|
|
Refer to specific center
|
64
|
6.18
|
Abbreviations: SD, standard deviation; TR, Teleregulation.
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.[8] 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.[8] 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.[8]
[9] 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.[10] A recent review suggested that teleconsultations should be encouraged in the care
of these patients.[11]
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%.[12] 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.[13]
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.[14] According to the Curitiba municipal health secretary, the median waiting time for
a specialist consultation is 10 months.[15]
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.
