ARTICLE IN BRIEF
Researchers documented wide disparities between low-income and high-income countries in terms of access to diagnostic testing and procedures for neurologic disorders.
WASHINGTON—Diagnostic testing for neurologic conditions is least available in the lowest-income countries, according to the results of a survey sent to neurologists around the world presented here at the AAN Annual Meeting in April.
And even if tests are available, they are often not very accessible or affordable, according to the findings from researchers at the University of Pennsylvania, Harvard University, and Queen's University in Kingston, Ontario.
“Very little is known about the general availability of testing for neurologic disorders, especially in low and middle-income countries,” said Hannah McLane, MD, MA, MPH, a neurology resident at the University of Pennsylvania, who presented the findings. “Even when human resources and technology are available, it's not clear what proportion of the population have access to neurodiagnostic testing, given the general uneven distribution of health resources in lower and middle-income countries. We identified disparities within countries — especially between public and private — as well as between countries based on the World Bank income group.”
The survey of physicians engaged in the practice of neurology included 60 multiple choice and fill-in-the-blank questions, with subsequent questions asked based on answers already given. The physicians were found through professional societies and through contacts known to the researchers.
They received 52 responses from 37 different countries, but used just one survey response for each country, so that the responses were not skewed to reflect one country's circumstances more than another's; the main focus was on the tiers of a country's income. Physicians were asked about electroencephalogram (EEG), electromyography (EMG), head computed tomography (CT), lumbar puncture, and magnetic resonance imaging (MRI).
Low-income countries were considered to be those with a gross national income (GNI) per capita of less than $1,045, according to World Bank figures; lower-middle was classified as having a GNI of $1,045 to $4,125; upper-middle, $4,125 to $12,746; and high-income countries were considered to be those with a GNI per capita of more than $12,746.
Availability was defined as the routine existence of the testing procedure, usable by patients at the respondent's health care facility. Access time was the amount of time a patient would typically have to wait for a procedure to be done. Affordability was based on the out-of-pocket cost and patient's ability to pay.
Researchers found that availability was positively correlated with the higher World Bank income group for EEG (p=0.046) and EMG (p=0.043). These tests were said to be available in just five of eight low-income countries, but available in all nine of the high-income countries.
Access time for MRI was found to be particularly poor for patients in public health systems in low-income countries; none reported that MRI was available within 48 hours and three of five reported that the wait was longer than six months.
Only 17 percent of low-income country respondents said an urgent head CT for acute stroke would be available within 4.5 hours to the majority of the patients within the public health care system, compared with 67 percent of low-income country respondents in the private health care system. One hundred percent of all high-income country respondents said the majority of their patients could receive a head CT in that time frame, regardless of whether the systems were public or private.
Longer wait times were also reported for EEG in public systems compared with private systems, although strong links to income bracket were not seen.
Researchers reported that tests were more affordable in upper-middle and high-income countries. The cost of an average test was more than 20 percent of per capita gross domestic product in low-income countries and about 5 percent in lower-middle-income countries, compared with less than 5 percent for countries in the upper two brackets.
They also found that in high-income countries, more than 80 percent of the population could afford a given test, whereas in low-income countries, less than 20 percent of the population could afford the tests.
“Beyond the barrier of unavailability of these tests, many people in low-income countries and lower-middle-income countries also face long wait times and low affordability, which likely contributes to morbidity and/or mortality of neurologic disorders,” Dr. McLane said. “Many neurodiagnostic tests are the least available, accessible, and affordable in the lowest-income countries where the majority of the world's population resides. Closing this diagnostic gap is essential in determining the global burden of neurologic disease and improving outcomes for people with neurologic disorders in the lowest-income settings.”
Nirali Vora, MD, a clinical assistant professor and director of global health neurology at the Stanford School of Medicine, said the data are another indication that neurology needs to be improved abroad — and not just in terms of diagnostics.
“The diagnostic gap illustrated by the authors suggests our current understanding of the global burden of neurological disease is inaccurate, and I suspect under-represented,” she said. “Epidemiological data drives local and global policymakers when it comes to resource allocation, so having accurate data is critical. Identifying and measuring disparities is the first step to correcting them.”
But, she added, “the correction won't take place by providing more neuro-diagnostic tools to resource-limited countries; that is just a proxy, in my opinion, to the under-representation of neurologists. The WHO Neurology Atlas already demonstrated this back in 2004.” The study — a compilation of information on neurological resources in 109 countries — showed that in the US and Europe, there are more than five neurologists per 100,000 people, while countries in central Africa and the Middle East have 0.1 neurologists or fewer per 100,000 people.
Dr. Vora said she believes it's the duty of neurologists in the US and other countries with well-established neurology programs to help create greater neurology capacity in low-income countries, through teaching and developing “sustainable education programs” for training neurologists.
“Once local neurology leaders and infrastructure are in place in these countries, the tools of the trade and their accurate interpretation should follow,” she said.
“In the meantime,” she added, “neurology leaders who develop diagnostic and treatment guidelines should consider the mismatch between typical recommendations that depend on high use of neurodiagnostics and what is feasible in lower-income environments. Partnerships between countries with and without neurology specialties must be forged to identify alternative recommendations on how to manage these patients in resource-limited settings.”
She said that the presence or absence of a diagnostic tool is just “the tip of the iceberg” and that many more research questions remain regarding the unmet needs in neurological care in low-income countries.
“What percent of patients were delayed in reaching a physician with neurology expertise or completing a diagnostic study, and how often was that delay due to money, geographic distance from appropriate care, or lack of a functioning machine?” she said. “What percentage of physicians in low-income countries and lower-middle-income countries feel comfortable interpreting CT, MRI, and EEG, and if not, what additional training is required?”