Neurological Healthcare Services In Australia & New Zeland

Neurological conditions are the principal cause of long-term disability globally. However, for most patients worldwide, the existing neurological healthcare services are poor. In low-income countries, most people do not have access to appropriate neurological care, whereas in developed countries, distance and disability hinder such services (Dorsey, Glidden, Holloway, Birbeck, & Schwamm, 2018). With an aging population, and the ever-increasing incidence of stroke, dementia, and other neurodegenerative diseases, the problem will only get worse. According to the American National Center for Health Workforce Analysis, despite there will be an increase in the US neurologists by 11% between 2013 and 2025, the corresponding demand is expected to grow by 16%.

In Australia, in particular, a survey conducted by the Australian and New Zealand Association of Neurologists (ANZAN) in collaboration with the Royal Australasian College of Physicians indicates that there is 1 neurologist per 50,000 people over most of New South Wales, Victoria, South Australia and the Australian Capital Territory. However, the neurologist-to-patient ratio is lower in regional areas and the Northern Territory (Burton, 2018).The telecom evolution has been exploited in various ways to deliver healthcare at a distance, creating a new field, known as telemedicine. Providing specialist consultations through video-conferencing, while monitoring and giving clinical instructions for self-management to patients with chronic diseases in remote areas is now a proven reality. Even electronic patient records can be shared via systems that transfer high volumes of audiovisual data at high speed, through fixed or mobile devices (Flodgren, Rachas, Farmer, Inzitari, & Shepperd, 2015).

By that means, healthcare services become accessible even in isolated communities, ensuring continuous care and full use of the existing medical resources (Di Cerbo, Morales-Medina, Palmieri, & Iannitti, 2015).Teleneurology is a branch of telemedicine, utilizing innovative telecommunication technologies that offer neurological assessment and assistance when the physician and patient are not present in the same place, and likely not at the same time. Therefore, this approach would benefit people in rural areas with limited access to general and specialized neurological services, like neurorehabilitation, patients with impaired mobility, and deployed military personnel (L. R. Wechsler, 2015). In low-income regions, teleneurology can scale up professional development, support the diagnostic process and offer consultations. In high-income areas, it could foster the spread and allocation of neurological care away from institutions, introduce asynchronous communication, induct healthcare professionals with various expertise and reach out to new communities (Dorsey et al., 2018).

Through real-time video communication, imaging, and data sharing, a greater number of neurologists can fill the supply-demand gap in medically underserved populations. Moreover, teleneurology can significantly reduce the response time for acute neurological evaluation, can take the place of or be ancillary to in-office visits and enhance the level of cooperation between primary care providers, neurologists and other specialties (Martina et al., 2018). A real-time patient observation in his/her home with a dynamic broadcast of the patient's movements through live interaction could provide a more comprehensive view of the patient's condition in his/her environment and thus offer an apposite solution to his/her problem. Telehealth systems are able to meet these needs by providing remote audiovisual live streaming. Their efficacy has been already been proved in acute stroke care (Handschu et al., 2014).

Besides, Durner et al reported that establishing a 24/7 live broadcast telemedicine home treatment system in Parkinson’s Disease patients could be feasible demonstrating a good patient satisfaction rate (Durner et al., 2017). Through live streaming connections the delay between recording, video evaluation, and informing the patients about therapeutical adjustments is eliminated, ensuring instant help in acute problems.Telestroke has already fulfilled this promise. Telehealth facilitates the access to optimum stroke management, expediting treatment and providing the newest interventions, such as endovascular clot retrieval (Cadilhac et al., 2018). It has been demonstrated that telestroke can raise the thrombolysis rate in small rural hospitals with reduced time to intervention and can offer cost-effective, long-term services (Christopher F Bladin & Cadilhac, 2014).

As an example, in Australia, during the first year of The Victorian Stroke Telemedicine programme implementation, compared to previous data, stroke thrombolysis increased from 17% to 26%, whereas the percentage of patients that received tissue thromboplasminogen activator and were discharged to home or rehabilitation raised significantly from 33% to 80% (C. F. Bladin et al., 2015). In addition, the quality of care as well as short-term and long-term mortality remain similar between stroke telemedicine and in-person consultation (Amadi-Obi, Gilligan, Owens, & O’Donnell, 2014). Although, currently, telestroke aims at achieving universal equivalence with face-to-face management, there is the possibility for further expansion and improvement. Even in regions with available stroke expertise, telemedicine could expedite or provide quality assistance, increasing protocol adherence and improving further the outcomes (Lawrence R Wechsler et al., 2017).

Telestroke has led the way for other subspecialties in neurology to utilize this technology. Yet, unlike stroke, teleneurology application for chronic conditions is still in its infancy. However, studies so far point to effective and quick neurology care in communities with limited neurology resources, reducing the waiting time for hospital evaluation even from 2 months to 7 days (Hack, Osorio, & Reimers, 2018). As medical history is essential for chronic diseases, telemedicine also allows the creation of accurate and secure electronic medical records, providing ongoing, comprehensive specialized care for those patients (Haddad, Grant, & Eswaran, 2015).As an example, Müller et al. show that telemedicine can eliminate misdiagnoses, provide accurate and fast treatment and avoid unnecessary travel in the management of headache, an aspect particularly important for people with disability and reduced autonomy living in remote areas (Kai I. Müller, Karl B. Alstadhaug, & Svein I. Bekkelund, 2017).

These findings are in line with their previous results that showed that telemedicine is an accepted, feasible, time- and cost-saving alternate option to conventional consultation for non-acute headache, even in terms of long-term efficacy and satisfaction (Müller, Alstadhaug, & Bekkelund, 2016; K. I. Müller, K. B. Alstadhaug, & S. I. Bekkelund, 2017).Without a doubt, teleneurology attracts increasing interest of physicians who begin to apply it, among others, to the treatment of movement disorders. An international online survey recruiting Movement Disorder Society members showed that telemedicine can reduce travel time almost by 93% and patient costs by 60% (Anhar et al., 2018). Besides, it can provide equally efficient clinical care as the in-office visits (Ben-Pazi et al., 2018). Since healthcare shifts toward patient-centered approaches, patient satisfaction is a key element for the evaluation of medical services. In a recent study, neurology patients living in rural areas demonstrated considerable interest in participating in teleneurology for routine follow-up visits. This increased interest was attributed to the following factors: 68.9% had to travel more than one hour to the hospital, 22.6% had missed their medical appointments because of travel issues, and 43.1% faced travel-imposed economic distress (Bashiri, Greenfield L, & Oliveto, 2016).

Direct-to-home, high-quality neurological telemedicine is a feasible alternative that is welcomed and appreciated by patients, their caregivers and neurologists (Wilkinson et al., 2016). Comprehensive and seamless induction of telehealth into chronic neurological disorders is not only possible but also preferred by patients over long-distance, time-consuming travel. Moreover, this approach promotes a solid relationship between physicians that may be lost in a more conventional referral-based model. In a relevant study regarding dementia patients, physicians and patient-caregivers primarily noted that teleneurology was more convenient compared to in-person visits. Additionally, all patients along with their caregivers felt that they received satisfactory care and had good communication during the process (Erten-Lyons et al., 2016).

Those findings are supported by a similar study, where telemedicine outperformed office visits in terms of convenience, time, expenses and quality of service. In particular, overall satisfaction had a median score of 9.5/10, whereas comparative satisfaction favored telemedicine (9.5/10). In the same study, the average set-up time for patients was only 25 min, in contrast to an estimated 2 hour commitment required for a round trip. Regarding neurology providers, they rated the quality of service during telemedicine visits as equivalent to office consultations (Hanson, Goetz, Truesdell, Stebbins, & Weathers, 2017).As evidenced by the research, teleneurology can deliver high quality patient care for a variety of chronic neurologic conditions, providing comparable care to neurological in-person institutions.

According to a survey, patients highlighted the convenience and quality of their teleneurology consultation, and, in turn, the neurologists were convinced that teleneurological care can be as effective as clinic follow-up visits. Moreover, the median time savings were calculated in 5 hours and 325 miles driven, besides a minimum of $48,000 total cost savings (Davis, Coleman, Harnar, & King, 2014). In line with their previous results, Davis et al, in a more recent study, where neurology patients of rural areas and neurology staff participated in a teleneurology programme, showed that approximately 90% of the patients felt they received good care and had good communication, 88% were pleased by the convenience, while 87% expressed their desire to pursue teleneurology care. Finally, 96% reported they saved time, money, or both through this programme instead of travelling to the nearest city (Davis et al., 2018).

Furthermore, neurology telemedicine can significantly cut patient and healthcare system costs by avoiding unneccessary testing or referrals to the emergency department without compromising clinical safety and efficacy (Bove et al., 2018). To this end, proper training, protocol establishment and further operational development is of utmost importance. In a relevant survey, although the patient satisfaction with the telehealth system was 4.65 out of 5 and most users were interested in continuing with teleneurology, the lack of experience on behalf of some telemedical nurses was a leading cause of patient frustration (Qiang & Marras, 2015). In another study among patients with dementia, the outcomes have been overwhelmingly positive with overall satisfaction at 4.84 out of 5, whereas general satisfaction with the neurologist and with the telemedicine system reached 4.88/5 and 4.65/5, respectively. Of note, although a lot of patients were initially hesitant to participate in a video consultation due to their hearing impairment, eventually the process ran smoothly with reliable videoconferencing equipment (Tso, Farinpour, Chui, & Liu, 2016). Given the facts, it seems that nearly all of teleneurology patients would favour further video consultation over travel and in-person attendance (Adamson, Smit, & Costello, 2017).Discrepancies in access to healthcare, in particular specialist expertise, exist throughout the world. As the prevalence of chronic neurological disorders increases with ageing populations, access to neurologist care is likely to worsen in many regions if there are no changes to models of care (Schneider & Biglan, 2017).

Telemedicine encompasses diverse modalities; however, synchronous or “real-time” systems provide the optimal patient experience -a key aspect of interactive teleneurology- reaching in most cases 98% satisfaction with significant time and cost savings for the patient (Waibel, Cain, Hall, & Keen, 2017). As approximately 6%–10% of primary care visits result in specialty referral, teleneurology can leverage technological advances to reach underserved populations (Flodgren et al., 2015). The encouraging outcomes of its current implementation may contribute to a more extensive and less expensive care for patients, especially those in regions with no or limited neurological services.