Using Teleneurology to Deliver Chronic Neurologic Care to Rural Veterans: Analysis of the First 1,100 Patient Visits.

BACKGROUND: A challenge confronting the United States is delivery of quality specialty healthcare to citizens living in rural areas. INTRODUCTION: The Veterans Administration (VA) developed a large national telehealth network to address 5.2 million rural veterans. New Mexico's Albuquerque VA Neurology Service developed a teleneurology program for their rural veterans. This article analyzes our first 1,100 teleneurology patient visits. MATERIALS AND METHODS: Veterans living in remote areas of New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 16 rural VA community-based outpatient clinics (CBOCs) following an initial evaluation at the Albuquerque VA neurology outpatient clinic. Surveys were sent after all teleneurology visits focused on quality of care, ease of communication, satisfaction, and staff's ability to deliver same quality care as in person. Problems encountered, differences between face-to-face clinics and teleneurology, and cost savings were examined. RESULTS: Regarding the 701 (64%) returned surveys, we found 90% perceived they received good care, 91% felt there was good communication, 88% liked the convenience, and 87% reported they desired to continue teleneurology care. Ninety-six percent reported saving time, money, or both through CBOC visits instead of driving to Albuquerque. DISCUSSION: All providers felt that they could deliver excellent care through teleneurology. We found emergency room visits for neurologic problems was similar for both groups. CONCLUSIONS: Our rural veteran patients and neurology staff overwhelmingly found high quality patient care can be delivered via teleneurology for a variety of chronic neurologic problems and was comparable to care delivered in neurology face-to-face clinics.

Teleneurology: successful delivery of chronic neurologic care to 354 patients living remotely in a rural state.

BACKGROUND: Delivery of specialty healthcare to rural citizens in the United States remains largely unmet. The Veterans Health Administration is in a unique position to deliver specialty care to rural Veterans because it is mandated to deliver medical care to all eligible Veterans regardless of residence. To accomplish this, the VHA developed large national telehealth networks that provided over 1 million episodes of care in 2012. We investigated whether clinical video telehealth technologies can provide quality efficient neurologic follow-up care to Veterans living in the rural southwest United States. PATIENTS AND METHODS: Veterans with chronic neurologic conditions living remotely in New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 11 rural community-based outpatient clinics following initial evaluation at the Albuquerque, NM, neurology outpatient clinic. RESULTS: Over a 2-year period, 87% of 354 consecutive patients returned a performance improvement satisfaction questionnaire. Ninety percent of the patients were fully satisfied with their visit, and 92% felt teleneurology saved them time and money. We calculated an average time savings of 5 h and 325 miles driven, plus at least $48,000 total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology. CONCLUSIONS: Our study confirms earlier pilot studies of successful follow-up care through telemedicine. Our patients were highly satisfied with the convenience and quality of their teleneurology visit, and the neurology providers were convinced that neurologic care to both teleneurology and clinic follow-up patients was equivalent. Teleneurology to rural Veterans can provide quality neurologic care and overwhelming patient satisfaction and save considerable time and money.

Rehabilitation plus OnabotulinumtoxinA Improves Motor Function over OnabotulinumtoxinA Alone in Post-Stroke Upper Limb Spasticity: A Single-Blind, Randomized Trial.

BACKGROUND: OnabotulinumtoxinA (BoNT-A) can temporarily decrease spasticity following stroke, but whether there is an associated improvement in upper limb function is less clear. This study measured the benefit of adding weekly rehabilitation to a background of BoNT-A treatments for chronic upper limb spasticity following stroke. METHODS: This was a multi-center clinical trial. Thirty-one patients with post-stroke upper limb spasticity were treated with BoNT-A. They were then randomly assigned to 24 weeks of weekly upper limb rehabilitation or no rehabilitation. They were injected up to two times, and followed for 24 weeks. The primary outcome was change in the Fugl-Meyer upper extremity score, which measures motor function, sensation, range of motion, coordination, and speed. RESULTS: The 'rehab' group significantly improved on the Fugl-Meyer upper extremity score (Visit 1 = 60, Visit 5 = 67) while the 'no rehab' group did not improve (Visit 1 = 59, Visit 5 = 59; p = 0.006). This improvement was largely driven by the upper extremity "movement" subscale, which showed that the 'rehab' group was improving (Visit 1 = 33, Visit 5 = 37) while the 'no rehab' group remained virtually unchanged (Visit 1 = 34, Visit 5 = 33; p = 0.034). CONCLUSIONS: Following injection of BoNT-A, adding a program of rehabilitation improved motor recovery compared to an injected group with no rehabilitation.

Persistent neuropsychological impairment associated with West Nile virus infection.

West Nile virus infection can result in prolonged subjective complaints of cognitive and functional decline even in the absence of a neuroinvasive form of infection. Persistent cognitive and functional complaints could be a result of general somatic symptoms, emotional distress, or residual central nervous system damage or dysfunction. Most studies of cognition in postacute West Nile virus infection rely on self-report. This descriptive study aimed to document cognitive deficits in a sample of the 2003 infected population reported in New Mexico. Patients with clinically defined neuroinvasive disease or who were impaired on brief mental status screening were seen for comprehensive neuropsychological assessment. We found that one year after symptom onset, more than half of the sample had objectively measurable neuropsychological impairment in at least two cognitive domains. Impairment was not related to subjective complaints of physical or emotional distress, or premorbid intellectual abilities. Persistent cognitive impairment in West Nile virus infection may be due to prolonged or permanent damage to the central nervous system.

West Nile virus neuroinvasive disease.

Since 1999, there have been nearly 20,000 cases of confirmed symptomatic West Nile virus (WNV) infection in the United States, and it is likely that more than 1 million people have been infected by the virus. WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future. Clinical syndromes produced by WNV infection include asymptomatic infection, West Nile Fever, and West Nile neuroinvasive disease (WNND). WNND includes syndromes of meningitis, encephalitis, and acute flaccid paralysis/poliomyelitis. The clinical, laboratory, and diagnostic features of these syndromes are reviewed here. Many patients with WNND have normal neuroimaging studies, but abnormalities may be present in areas including the basal ganglia, thalamus, cerebellum, and brainstem. Cerebrospinal fluid invariably shows a pleocytosis, with a predominance of neutrophils in up to half the patients. Diagnosis of WNND depends predominantly on demonstration of WNV-specific IgM antibodies in cerebrospinal fluid. Recent studies suggest that some WNV-infected patients have persistent WNV IgM serum and/or cerebrospinal fluid antibody responses, and this may require revision of current serodiagnostic criteria. Although there is no proven therapy for WNND, several vaccines and antiviral therapy with antibodies, antisense oligonucleotides, and interferon preparations are currently undergoing human clinical trials. Recovery from neurological sequelae of WNV infection including cognitive deficits and weakness may be prolonged and incomplete.