Implementation Science to Improve Quality of Neurological Care.

Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.

Quality of Neurologic Care in the United States: Initial Report From the Axon Registry.

OBJECTIVE: To provide the initial description of the quality of outpatient US neurologic care as collected and reported in the Axon Registry. METHODS: We describe characteristics of registry participants and the performance of neurology providers on 20 of the 2019 Axon Registry quality measures. From the distribution of providers' scores on a quality measure, we calculate the median performance for each quality measure. We test for associations between quality measure performance, provider characteristics, and intrinsic measure parameters. RESULTS: There were 948 neurology providers who contributed a total of 6,480 provider-metric observations. Overall, the average quality measure performance score at the provider level was 66 (median 77). At the measure level (n = 20), the average quality measure performance score was 53 (median 55) with a range of 2 to 100 (interquartile range 20-91). Measures with a lower-complexity category (e.g., discrete orders, singular concepts) or developed through the specialty's qualified clinical data registry pathway had higher performance distributions. There was no difference in performance between Merit-Based Incentive Payment System (MIPS) and non-MIPS providers. There was no association between quality measure performance and practice size, measure clinical topic/neurologic condition, or measure year of entry. CONCLUSIONS: This cross-sectional assessment of quality measure performance in 2019 Axon Registry data demonstrates modest performance scores and considerable variability across measures and providers. More complex measures were associated with lower performance. These findings serve as a baseline assessment of quality of ambulatory neurologic care in the United States and provide insights into future measure design.

An Objective Structured Clinical Examination of Communication Skills for Child Neurology Residents.

BACKGROUND: The purpose of this study was to implement an objective structured clinical examination for child neurology trainees for formative feedback regarding communication skills. Effective communication skills are essential and teachable, but tools to formally assess them are limited. An objective structured clinical examination is one such tool, but these examinations have not been developed for child neurology residents. METHODS: We developed nine standardized scenarios that highlighted communication challenges commonly encountered in child neurology. Child neurology trainees participated in three objective structured clinical examination events with three scenarios each over three academic years. Standardized patients portrayed patients or their parents. Each trainee-standardized patient encounter was evaluated by an observing faculty member using a modified Gap-Kalamazoo Communication Skills Assessment Form, the standardized patient who provided direct feedback, and by the participating trainee. RESULTS: We refined the process of case writing, standardized patient training, and trainee evaluation throughout the three-year pilot. Results indicated rater agreement ranging from 32% to 56%. Trainees reported that the cases were challenging and reflective of real life and that the experience helped improve their communication skills. CONCLUSIONS: An objective structured clinical examination can provide a standardized setting for formative feedback regarding communication skills in child neurology residency programs. The communication challenges posed by common clinical scenarios involving critically ill children, children with undetermined prognosis, and the triad of parent, child, and physician can be realistically modeled in an objective structured clinical examination. We developed cases and a process that were valuable and that we plan to sustain for resident education related to communication skills.

Developing a New Set of ACGME Milestones for Child Neurology Residency.

BACKGROUND: The Educational Milestones developed by the Accreditation Council for Graduate Medical Education (ACGME) are a construct used to evaluate the development of core competencies during residency and fellowship training. The milestones were developed to create a framework for professional development during graduate medical education. The first iteration of milestones for the child neurology residency was implemented in 2015. In the years that followed, the ACGME received and reviewed feedback about the milestones and set out to revise them. METHODS: A committee was assembled to review the original milestones and develop a new set of milestones. The group was also encouraged to not only consider the child neurology residency graduate of today but also the graduate of tomorrow, taking into account growing fields such as genetics and technology. RESULTS: A diverse group of 12 individuals, including 10 child neurologists (all of whom were current or previous program directors or associate program directors), one child neurology resident, and one non-physician program coordinator, were recruited from programs of varying size across the country. CONCLUSIONS: The committee developed a revision to the child neurology milestones. All changes made were with a focus on how the milestones can be useful to trainees, program directors, and clinical competency committee members. Implementation and further feedback should help guide future revisions. These changes should help trainees, clinical competency committee members, and program directors find more meaning from their use.

Real-time Assessment of Neurology Residents' Perceptions of Inappropriate Consults.

BACKGROUND: We sought to characterize perceptions of inappropriate neurology consults of neurology residents (NR) and requesting providers (RP) immediately following the consult interaction. METHODS: Student investigators were embedded in the Mount Sinai neurology consult service for 4 weeks in May/June 2018. For each consecutive neurology consult the NR's real-time attitudes toward the consult were evaluated with a survey using Likert scales. A similar survey was immediately administered to the RP who called the consult. Response scores for each attribute were dichotomized and data were analyzed descriptively in SPSS. RESULTS: Data from 69 consults were collected. NRs perceived 45% of consults as inappropriate and 82% of all consults as low urgency. When NRs perceived a consult as inappropriate, they felt more resistance (r=-0.79). NRs also felt more resistant when they thought that the RP could have cared for the patient without the consult (r=0.79). NRs felt that perceived medicolegal risk highly influenced the RP's decision to call a consult in 36% of cases. Of these "high liability" consults, NRs considered 76% inappropriate and 100% low urgency. CONCLUSIONS: NRs were more likely to rate consults as inappropriate if they were also perceived as low urgency, strongly influenced by liability concerns, or unnecessary due to belief that the RP could have cared for the patient without the consult. Our findings suggest a discrepancy in how NRs and RPs perceive neurology consult appropriateness, and help to elucidate potential drivers of these perceptions that could be barriers to education and to interdisciplinary care.

Clinical Magnetoencephalography Practice in the United States Ten Years Later: A Survey-Based Reappraisal.

PURPOSE: Broader utilization of magnetoencephalography (MEG) and optimization of clinical practice remain strategic goals of the American Clinical Magnetoencephalography Society. Despite the implementation of the first MEG Clinical Practice Guidelines, clinical adoption has been less than expected, prompting a reassessment. METHODS: Twenty-five clinical MEG centers were invited to participate anonymously in a survey of clinical practice. RESULTS: Centers (N = 18) mostly operated within an academic medical center (10/18), were owned by the "hospital" (10/18), associated with a level 4 National Association of Epilepsy center (15/18), and directed by neurologists (10/18). A total of 873 (median 59) epilepsy studies, 1,179 evoked fields (of all types), and 1,607 (median 30) research MEG studies were reported. Fourteen of 17 centers serve children (median 35%), but only 5 of 14 sedate children for MEG. All (N = 14) centers record EEG simultaneous with MEG, and 57% used dipole source localization. The median reporting time for epilepsy studies was 12 and 10 days for presurgical mapping studies. Most (12/14) were favorable toward the Clinical Practice Guidelines and "formalized certification" but were against mandating the latter. CONCLUSIONS: A plateau in MEG volumes suggests that MEG has not become a part of the standard of care, and correspondingly, the Clinical Practice Guidelines appeared to have had little impact on clinical practice. The American Clinical Magnetoencephalography Society must continue to engage magnetoencephalographers, potential referrers, and vendors.

Adherence to American Heart Association/American Stroke Association Clinical Performance Measures in a Peruvian Neurological Reference Institute.

BACKGROUND: Little is known about adherence to American Heart Association/American Stroke Association (AHA/ASA) stroke performance measures in developing countries like Peru. AIMS: We assessed adherence and determined factors associated with adherence to the AHA/ASA stroke performance measures at a reference center for neurological diseases in Lima, Peru. METHODS: We conducted a retrospective chart review of 150 stroke patients admitted to the Neurological Institute of Neurological Science from 2014 to 2016 to ascertain adherence to 15 different AHA/ASA stroke performance measures. Adherence was measured as a simple proportion, with both single and composite measures. Associations were analyzed with nonparametric statistics and multivariate logistic regression. RESULTS: Mean adherence to AHA/ASA stroke performance measures was 47%. We observed a statistically significant relationship between adherence to ischemic stroke performance measures and being married (OR = 3.78, 95% CI: 1.05-13.55), as well as an inverse relationship with an onset of symptoms of greater than 4.5 h prior to arrival at the hospital compared to those with ≤ 4.5 h (OR = 0.14, 95% CI: 0.02-0.97). Compared to patients with a lower National Institutes of Health Stroke Scale (NIHSS) score (<13), those with a score of ≥13 were less likely to have good adherence (OR = 0.11, 95% CI: 0.04-0.31). CONCLUSIONS: The mean composite measure of adherence to internationally recognized standards of stroke management in our Peruvian institution was below the level needed for an achievement award by AHA/ASA. An intervention targeted toward stroke prevention and training could lead to improved outcomes of stroke patients in Peru.

The Unease When Using Anesthetics for Treatment-Refractory Status Epilepticus: Still Far Too Many Questions.

Status epilepticus (SE), treatment-refractory status epilepticus (RSE), and super-treatment-refractory status epilepticus (SRSE) are associated with increased morbidity, mortality, and high socioeconomic burden and pose significant treatment challenges for intensivists and neurologists. To optimize and streamline emergency treatment, current practice guidelines recommend the use of continuously delivered intravenous anesthetic drugs such as midazolam, propofol, or barbiturates as the third-line therapy after first-line and second-line treatments have failed. Although the rationale for these third-line drugs seems intuitive at first glance, there is a clear paucity of evidence-based data on risks, benefits, and even on the choice of a third-line agent. Recent studies into safety and efficacy reveal disturbing results, such as a poor outcome and higher mortality associated with the use of intravenous anesthetic drugs, especially in patients with nonconvulsive SE without coma and in patients with out-of-hospital SE onset. Clinicians should deliberately weigh the advantages and disadvantages of intravenous anesthetic drug therapy in patients with different types of SE usually linked to a favorable outcome (i.e., simple partial, complex partial, or absence seizures). The lack of data to support evidence-based medicine prompts a careful balance of individual risks and benefits of intravenous anesthetic drug therapy in patients with SE, treatment-refractory SE, and super-RSE.

Gender Disparity and Potential Strategies for Improvement in Neurology and Clinical Neurophysiology.

Discrimination in the workplace when documented is illegal but is seen to still exist in some forms whether based on culture, race, or gender. Each of these disparities warrants further discussion and study because of their significant impacts on hiring decisions, career advancement, and compensation. In this article, the authors have focused their attention on gender disparity in the fields of neurology and clinical neurophysiology and shared the data currently available to them. At a time when the field of clinical neurophysiology has seen enormous growth, gender disparity in leadership and compensation remain. Despite the increasing number of women entering the fields of neurology and clinical neurophysiology, women remain underrepresented in national leadership positions. Many women physicians report experiencing gender discrimination despite increasing efforts by universities and medical centers to improve inclusivity and diversity. Equity and inclusivity are not the same and there is a disconnect between the increased numbers of women and their shared experiences in the workplace. Implicit bias undermines the ability of women to advance in their careers. For neurologists, data indicate that the latest gender pay gap is $56,000 (24%), increased from $37,000 in 2015, and is one of the largest pay gaps in any medical specialty. One third of the top 12 medical schools in the United States require that maternity leave be taken through disability coverage and/or sick benefits, and most family leave policies constrain benefits to the discretion of departmental leadership. The authors recommend strategies to improve gender disparity include institutional training to Identify and overcome biases, changes to professional organizations and national scientific meeting structure, transparency in academic hiring, promotion and compensation, and mentorship and sponsorship programs.

Attitudes and knowledge about cannabis and cannabis-based therapies among US neurologists, nurses, and pharmacists.

Use of cannabinoid therapies is on the rise in the United States, but responses of healthcare professionals and their knowledge of these therapies have been mixed. More information is needed about factors associated with healthcare professionals' attitudes and knowledge about medical cannabis. We conducted an online survey of US-based neurologists, nurse practitioners (NPs)/nurses, and pharmacists in August-September of 2018 (n = 451). We constructed perceived knowledge and attitudes scales and a knowledge index from multiple items and assessed state cannabis laws, participant's sociodemographics, workplace type and policies, and patient population. We used ordinary least-squares regression to examine associations among study variables. Over 80% of participants supported use and legalization of medical cannabis, especially cannabidiol (CBD) for epilepsy and when prescribed by a medical provider, but 40-50% (depending on item) felt unfamiliar with cannabinoid pharmacology and clinical applications. A total of 43% favored legal recreational cannabis. Pharmacists scored higher on the knowledge test than neurologists and NPs/nurses, but NPs/nurses had more favorable attitudes than neurologists and higher perceived knowledge than pharmacists. Both knowledge indicators predicted attitudes. State cannabis access and favorable workplace policies were associated with higher knowledge and more favorable attitudes. Healthcare professionals see potential in cannabis therapies but report significant knowledge gaps. Professional cannabinoid education is needed to address growing patient and provider demand for knowledge about cannabinoid therapies.

Consensus for prevention and management of coronavirus disease 2019 (COVID-19) for neurologists.

Coronavirus disease 2019 (COVID-19) has become a pandemic disease globally. Although COVID-19 directly invades lungs, it also involves the nervous system. Therefore, patients with nervous system involvement as the presenting symptoms in the early stage of infection may easily be misdiagnosed and their treatment delayed. They become silent contagious sources or 'virus spreaders'. In order to help neurologists to better understand the occurrence, development and prognosis, we have developed this consensus of prevention and management of COVID-19. It can also assist other healthcare providers to be familiar with and recognise COVID-19 in their evaluation of patients in the clinic and hospital environment.

The Virtual Neurologic Exam: Instructional Videos and Guidance for the COVID-19 Era.

OBJECTIVE: To outline features of the neurologic examination that can be performed virtually through telemedicine platforms (the virtual neurological examination [VNE]), and provide guidance for rapidly pivoting in-person clinical assessments to virtual visits during the COVID-19 pandemic and beyond. METHODS: The full neurologic examination is described with attention to components that can be performed virtually. RESULTS: A screening VNE is outlined that can be performed on a wide variety of patients, along with detailed descriptions of virtual examination maneuvers for specific scenarios (cognitive testing, neuromuscular and movement disorder examinations). CONCLUSIONS: During the COVID-19 pandemic, rapid adoption of virtual medicine will be critical to provide ongoing and timely neurological care. Familiarity and mastery of a VNE will be critical for neurologists, and this article outlines a practical approach to implementation.

Legal Liability Associated With rtPA Administration and Surrogate Decision Makers.

Stroke is one of the most common conditions neurologists treat in emergency situations. This article examines the issues of surrogate decision makers and the physician's potential legal liability in the context of the administration or nonadministration of recombinant tissue plasminogen activator (rtPA) in a common emergency department scenario.

Cannabis Treatment in Children with Epilepsy: Practices of Canadian Neurologists.

BACKGROUND: Medical cannabis has recently emerged as a treatment option for children with drug-resistant epilepsy. Despite the fact that many pediatric epilepsy patients across Canada are currently being treated with cannabis, little is known about the attitudes of neurologists toward cannabinoid treatment of children with epilepsy. METHODS: A 21-item online survey was distributed via email to 148 pediatric neurologists working in hospitals and community clinics across Canada. Questions were related to clinical practice and demographics. RESULTS: This survey achieved a response rate of 38% (56 Canadian neurologists). These neurologists were treating 668 pediatric epilepsy patients with cannabinoids. While 29% of neurologists did not support cannabis treatment in their patients, 34% prescribed cannabis, and 38% referred to another authorizing physician, mostly to community-based non-neurologists. The majority of neurologists considered cannabis for patients with Dravet syndrome (68%) and Lennox-Gastaut syndrome (64%) after an average of three failed anticonvulsants. Twenty-seven percent considered it for patients with idiopathic generalized epilepsy, and 18% for focal epilepsy. No neurologist used cannabis as a first-line treatment. All neurologists had at least one hesitation regarding cannabis treatment in pediatric epilepsy. The most common one was poor evidence (66%), followed by poor quality control (52%) and high cost (50%). CONCLUSIONS: The majority of Canadian pediatric neurologists consider using cannabis as a treatment for epilepsy in children. With many gaps in evidence and high patient-driven demand for cannabis therapy, this survey provides immediate information from the "wisdom of the crowd," to aid neurologists until further evidence is available.

Knowledge, attitude, and practice regarding atrial fibrillation among neurologists in central China: A cross-sectional study.

BACKGROUND: Physicians' knowledge and practice of atrial fibrillation (AF) are determinants of the efficacy of thromboprophylaxis. HYPOTHESIS: This study aimed to investigate physicians' knowledge, attitude, and practice toward AF, to analyze the influencing factors, and to provide data to support departments that develop health policies. METHODS: A cross-sectional study was carried out from October 1, 2016, to March 31, 2018. A standard-structured anonymous questionnaire was completed by each participant through face-to-face interviews. RESULTS: A total of 611 doctors from 38 hospitals were responded to this survey. The mean of the total score of the questionnaire was 21.59 ± 3.559 (total score of the questionnaire was 36), and the mean scores of knowledge, attitude, and practice were 6.86 ± 1.70, 6.13 ± 1.35, and 8.59 ± 2.21, respectively. The doctor' s knowledge, practice scores, and total scores were positively correlated with the education level and the workplace. The influencing factors that affect doctors' knowledge, attitudes, and practice scores including education level, professional title, working years, hospital grade, and hospital location. CONCLUSIONS: There was still a big gap in neurologists' knowledge and practice about AF. It is necessary to strengthen the continuous improvement of doctor training to improve the management of AF.

Clinical application of the PedsQL Epilepsy Module (PedsQL-EM) in an ambulatory pediatric epilepsy setting.

INTRODUCTION: Children with epilepsy report lower health-related quality of life (QOL) compared with healthy children and those with other chronic disorders. This study piloted the recently published Pediatric Quality of Life Inventory (PedsQL) Epilepsy Module (PedsQL-EM) in an ambulatory setting and studied epilepsy-related factors contributing to QOL in children with epilepsy. METHODS: Children with epilepsy aged 8-18 years who were ambulant and verbal were recruited from pediatric neurology clinics. Children and their caregivers completed age-appropriate versions of the PedsQL-EM (8-12 or 13-18 years) in the clinic waiting area. Treating neurologists completed medical questionnaires about their patients' epilepsy. RESULTS: We collected 151 parent-report and 127 self-report PedsQL-EMs. Administration time was 5-10 min with some children receiving assistance from the researcher. Mean age of children was 12.9+/-3.0, with 77 females (51%). Parents reported lower mean QOL scores across all subdomains compared with their children. Parents reported significantly lower QOL for children with earlier age at epilepsy onset, longer epilepsy duration, presence of seizures during the last month, more severe epilepsy, increased number of antiepileptic drugs (AEDs), and cognitive comorbidity. The same factors impacted on child self-reporting, but with more variability across subdomains. CONCLUSIONS: The PedsQL-EM is an epilepsy-specific measure of QOL that is quick and easy to administer and is sensitive to the clinical factors reported to impact on QOL in pediatric epilepsy.

Is the Neurological Disorders Depression Inventory-Epilepsy for Youth (NDDI-E-Y) more sensitive than a neurologist? A quality improvement project.

PURPOSE: Depression is one of the most prevalent psychiatric comorbidities in epilepsy. This quality improvement project compared a standardized rating scale, the Neurological Disorders Depression Inventory-Epilepsy for Youth (NDDI-E-Y), with physician opinion to see if it improved sensitivity to depressive symptoms. RESULTS: A convenience sample of thirty adolescents with epilepsy ages 12-17 (mean [M] = 15.02, standard deviation [SD] = 1.81; 53% female) participated in the screening. Thirteen percent of the sample scored in the Elevated range on the NDDI-E-Y (exceeded cutoff). Seven percent of the sample were rated by the physician as definitely showing signs of depression. There were two false negatives when the NDDI-E-Y score exceeded the established cutoff, but physician rating was negative for depressive symptoms. CONCLUSION: This pilot project shows that the NDDI-E-Y is a convenient clinical tool with the potential to improve sensitivity in the detection of depressive symptoms in adolescents with epilepsy.

Knowledge of and attitudes toward epilepsy surgery among neurologists in Saudi Arabia.

OBJECTIVE: To investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians` knowledge and attitudes. METHODS: A quantitative observational cross-sectional study conducted at King Saud University Medical City, Riyadh. The data were collected using a newly developed, self-administered online questionnaire. The questionnaire contained 3 sections: demographic information, knowledge, and attitudes which then sent to neurologist in Saudi Arabia from December 2016 to March 2017. RESULTS: A total of 106 neurologists met our inclusion criteria. Eighty percent of the participants had at least one epilepsy center in their city, and 78% indicated that they had access to adequate expertise and resources to enable the appropriate selection of epilepsy surgical candidates. Only 57.5% of the neurologists had a sufficient level of knowledge regarding epilepsy surgery. Neurologists with higher level of knowledge referred more patients to EMU and discussed epilepsy surgery more often with their patients. Overall, more than half of the neurologists (52.8%) had a positive attitude toward epilepsy surgery. There was a significantly positive correlation between the scores of knowledge and attitude (p less than 0.001). CONCLUSION: Neurologists in Saudi Arabia appear to have moderate knowledge of and positive attitudes toward epilepsy surgery. The place of the last neurology certificate, type of practicing hospital, and access to expertise and resources, affected their knowledge. Adequate knowledge was positively correlated with attitude.