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How Neurologists Address Patients' Needs in Rural Areas When the Practice Is Three Hours Away

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Neurologists from West Virginia, Utah, and Texas discuss how they meet patients' needs in rural areas using telemedicine and other initiatives in progress to address the neurologists shortage.

One neurologist says his patients travel three to four hours roundtrip for an office visit. Another works in a department that serves six states, in part, by shuttling staff by commuter airlines to remote clinics across the Southwest for two-week stretches at a time.

The use of telemedicine helps bridge gaps in access to care in some areas of the country where the neurologist-to-population ratios are low, particularly in rural states such as Utah, West Virginia, and Texas. But remote video conferencing is not always a perfect solution, and it comes with its own challenges, including poor quality technology and a lack of specialists trained to use it, neurologists in these states told Neurology Today.

In interviews, three neurologists from West Virginia, Utah, and Texas discussed how they address care for their patients in rural areas of their states, how they're using telemedicine, and other initiatives in progress to draw more neurologists to rural communities.

West Virginia

With a population of 1.8 million living across more than 24,230 square miles of the state, there are definitely areas where access to subspecialty care, particularly migraine, is under-served in West Virginia. The state, with only 125 AAN members, has only half of the neurologists it needs, David Watson, MD, associate professor, chairman, and director of the West Virginia University Headache Center estimated in an interview with Neurology Today.

Dr. Watson said roughly 20,000 people in the state have chronic migraine, the group that needs specialty care the most. And realistically, he said, 20,000 people can't be seen by a neurologist, or the four certified headache specialists in the state, three of whom are at West Virginia University in Morgantown, WV.

In a paper published earlier this year in Current Pain and Headache Reports, Dr. Watson and his colleagues highlighted how the health care system underserves people with migraine in rural areas.

He and his colleagues found that over the course of a month all patients seen in the WVU Headache Center spent an average of 70 miles to travel to the clinic—the furthest patient traveled 235 miles. Dr. Watson's patients spent a total of three to four hours roundtrip on a neurologic visit. Moreover, the costs of care included money for gas, eating on the road, and if they were employed, taking off half a day or a full day of work.

To increase the presence of neurologists in West Virginia, Dr. Watson and his colleagues are working on a telestroke program with several smaller hospitals in the state. They also have discussed using telemedicine for headache disorders, but it has not yet been implemented, partly because “we're so busy with our physical clinic that finding the time to be technologically available is challenging,” Dr. Watson said. “We try to use technology to reach people in an acute setting or a hospital to be helpful. We haven't been able to do this yet because of the neurologist shortage.”

One of the main challenges with teleservices is that some areas of the state do not have adequate broadband access, which would make doing teleservices challenging. “Most hospitals would have some sort of highspeed access, but if you're looking to do outpatient teleservices, then you'd be in a more clinical space, and some of the clinics do not have adequate broadband access,” Dr. Watson said

Currently WVU is trying to expand the neurology residency training program in West Virginia. “We're looking for ways to fund and support more training slots here for neurology residents,” Dr. Watson said.

Unfortunately, federal funding for these residency positions has been flat, according to Dr. Watson, so a new residency position can't be created with the hope that federal money will pay for it. “The first step is to convince the hospital of the value of a resident, including improved patient access, and then show the impact that residents can provide to a hospital system,” he said.

Dr. Watson and his colleagues are also looking at the possibility of getting funding from the hospitals in the state to help fund neurology residency positions to create a pathway, which would increase the likelihood that residents would choose to practice there. They are in the planning phases of reaching out to hospitals.

Dr. Watson said he and his colleagues are working with other health systems in the state—Marshall University in the southwestern part of the state, along with the Charleston Area Medical Center in Charleston, WV—to expand telestroke services. “We have some faculty that will do some clinical work with the system in Charleston and collaborate with the community hospital in town to provide neurologic coverage as well.”

“My goal has always been to figure out a way to work with people to take care of patients because there are way more patients than neurologists to take care of them, and we really don't need to be fighting over patients. We need to be working together to make sure everyone who needs us can be seen,” Dr. Watson said.

Stroke Therapist in Utah

With stroke, there's a very short time window when doctors are able to treat people, Jennifer Majersik, MD, MS, an assistant professor of neurology at University of Utah and director at the Stroke Center and Telestroke Network at University of Utah Health told Neurology Today. And this can be particularly difficult in a state where 3.2 million people are stretched across nearly 89 thousand square miles.

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“Its a big commitment. The hospital will fly us there through a commuter plane that will take multiple providers. The [neurology] department would like to expand for more rural communities, but we have to keep an eye on local need as well.”—DR. JENNIFER MAJERSIK

Dr. Majersik is working with her colleagues to increase the presence of telestroke at local hospitals in rural areas and recruit neurologists to these underserved communities.

“We serve six states, but 14 out of our 27 [telestroke] sites, are from Utah. We have super rural places in Utah, frontier sites that don't have critical access to hospitals, which serve Native American Navajo and Uintah communities,” said Dr. Majersik.

“We also serve parts of urban Salt Lake City, Northern Nevada, and southeast Idaho, southern Montana, and western Wyoming,” she said. “Due to the national shortage of neurologists, even some urban sites are struggling to get neurologists.”

Dr. Majersik said that even in small hospitals with on-site neurology, telestroke technology helps the neurologists maintain their practices. For example, in Vernal, UT, a mining town, neurologist Tom Buchanan, MD, has an extremely packed clinical practice where it's difficult for him to run into the emergency department and do acute stroke care.

“Dr. Buchanan once told me that ‘telestroke enables a rural neurologist like him to stay in business because he can focus on his clinical patients knowing his ER patients are getting good care while he stays in clinic,’” Dr. Majersik said.

“It allows the patient—no matter what their geography—to be seen by a stroke expert,” said Dr. Majersik. “It [also] allows for standard of care to be delivered even in places where that expertise isn't really known.”

However, Dr. Majersik said, teleneurology alone cannot address the disparities in health care that exists for patients in rural areas. Among her suggestions, Dr. Majersik suggest that neurologists could partner with primary care providers to train in neurology, to teach “bootcamps” or weekend courses, to increase the knowledge base and help better manage the need. This is something that all neurologists can help with, she said.

Tad Morley, executive director of Network Development and TeleHealth at University of Utah Health, told Neurology Today that to help lessen the disparity in access to care in rural communities, University of Utah Health is not only using telemedicine, but also sending neurologists to see the patients in these areas.

“We have one rural site we are taking neurologists out to where they provide a clinic there for those communities on a regular basis. That has a great asset to that community,” he said.

University of Utah Health has a neurologist working halftime in rural Idaho, and halftime in Salt Lake City, as well as neurologists working part-time in rural Wyoming.

“It's a big commitment. The hospital will fly us there through a commuter plane that will take multiple providers. The [neurology] department would like to expand to more rural communities, but we have to keep an eye on meeting the urban need as well,” Dr. Majersik said.

Another way University of Utah Health is bridging the gap to services is by allowing practicing in rural communities access to grand rounds, so that doctors and advance practice providers in those communities are all presented with specific cases involving more difficult or chronic health conditions.

“Specialists at the table are able to view cases and practitioners from different areas in the region are participating in these cases to learn from them and take that knowledge to their institutions,” said Morley.

In addition, a program called Project ECHO provides a free partnership that connects community providers and providers in rural areas with specialists at University of Utah Health.

The feedback has been very positive from participants and Utah Health faculty because “it serves as a very practical way of sharing information that is useful for those providing care to patients with less common conditions and it helps the provider with management in patient care,” Morley said.

Concussion and Sports Neurology in Texas

When concussion in an athlete is suspected, the lack of athletic trainers or other experienced providers in some rural areas can be problematic, said Bert B. Vargas, MD, FAAN, an associate professor of neurology at UT Southwestern in Dallas. Rapid access to specialty care may help prevent premature return to sport for some athletes which leaves them susceptible to greater risk for recurrent concussion or prolonged recovery.

Dr. Vargas, who led initial teleconcussion research initiatives while at the Mayo Clinic, believes telehealth makes it possible for patients in rural communities to access the same care as that of patients in metropolitan areas.

“When you consider the utility and the effectiveness of teleconcussion,” he said, “you have to be aware of the fact that the benefits are not limited to making remove from play decisions but also include the potential for making decisions about whether or not someone needs to be seen in an emergency department,” Dr. Vargas said.

After that, he added, that's when some of the evaluation and treatment decisions take place.

Teleconcussion programs have improved engagement between rural hospitals with providers in other locations. “Telemedicine programs allow them to be directly connected with the subspecialists they need at the time they need them,” Dr. Vargas said.

The relationships are important, he said, and I think the fact that there is a direct mechanism to get patients the care they need is important, and that may involve a decision to get that patient to a metropolitan center, when the needs of the athlete exceed the resources of their community.

Despite the use of teleconcussion in rural areas, Dr. Vargas emphasizes more needs to be done when it comes to access to concussion care. “There is a relative lack of providers with concussion expertise, like athletic trainers, in some communities and there is an even smaller number of sports neurologists. “We have a surplus of patients even in metropolitan communities that exceeds the supply of specialists,” he said.

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“Beyond teleconcussion we need to reach out and include advanced practice providers to participate in making informed remove and return-to-play decisions.”—DR. BERT B. VARGAS

Dr. Vargas attributes the short supply and growing demand to the fact more and more people are being referred to neurologists. “Texas is among the states where demand for neurologists outpaces the actual supply.”

“Beyond teleconcussion we need to reach out and include advanced practice providers to participate in making informed remove and return-to-play decisions,” he pointed out, noting that there are 300 medically underserved communities managed by advanced practice providers in the state of Texas.

At the state level, Dr. Vargas is advocating for initiatives that would allow advanced practice providers to assist with return-to-play decisions, especially in areas where there is a shortage of physicians serving those rural communities.

Drs. Vargas, Majersik, and Watson continue to be proactive in their initiatives to raise awareness of neurologists shortages in their states.

Overall, one of the reasons the demand for neurology is up, Dr. Watson said, is because “our ability to treat neurologic disease is improving. It's driving the demand for neurologists.”

Disclosures

Dr. Watson receives a stipend for participating in an advisory board for Eli Lilly & Co. Drs. Majersik and Vargas reported no disclosures. Morley had no disclosures.

Link Up for More Information

• Najib U, Moore M, Watson D, et al. Unique considerations for special populations in episodic migraine: The underserved https://link.springer.com/article/10.1007%2Fs11916-019-0749-1. Curr Pain Headache Rep 2019; Epub 2019 Feb 21.