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Can Teleneurology Bridge the Urban-Rural Divide in Health Outcomes?

Article In Brief

The divide between access to neurologic care in urban and rural areas has not diminished—even with the advent of telemedicine. Neurologists in rural areas discuss the challenges of providing care and the reasons why telemedicine has not been a panacea for bridging that divide in care.

The gap between rural and urban death rates tripled between 1999 and 2019, and life expectancy rates in rural counties decreased while urban counties posted increases between 2010 and 2019, according to a 2021 report in JAMA Network Open.

Many socioeconomic and other factors figure into these statistics, including lack of access to state-of-the-art care, said Muhib Kahn, MD, director of the Comprehensive Stroke Center at Spectrum Health in Grand Rapids, MI, who spoke about the inequities in a HeadTalk at this year's AAN Annual Meeting.

The disparities in health care outcomes are also compounded by the paucity of neurologists working in rural areas, Dr. Kahn and other neurologists doing health services research told Neurology Today. [See “The Data on the Urban-Rural Divide in Neurology.”]

Significant advances in the diagnosis and treatment of neurologic disease in the past two decades tend to be implemented first in the urban areas in which academic medical centers are located, Dr. Khan, section chief for vascular neurology, said in an interview with Neurology Today. “And it takes decades, at times, for those treatment options to be widely available to rural community patients.”

Although the prevalence of dementia, stroke, and other neurologic conditions is consistent across the US, people living in more rural areas are less likely to receive specialty care for certain conditions–dementia, pain, dizziness or vertigo, and sleep disorders–than those living in more urban areas, according to AAN-funded study published in 2020 in Neurology.

Another 2020 study published in Stroke found that rural patients hospitalized for stroke received intravenous thrombolysis or endovascular therapy significantly less frequently than their urban counterparts and had higher in-hospital mortality rates.

The new studies build on research by Brian Callaghan, MD, MS, FAAN, associate professor of neurology at the University of Michigan, and coauthors. Those researchers used 2015 Medicare physician data to summarize variation by Hospital Referral Region, a geographic classification system developed by the Dartmouth Atlas of Health Care, to study the distribution of neurologists across the county.

The regions with the fewest neurologists had, on average, 10 neurologists for every 100,000 people, while the regions with the most neurologists had an average of 43 neurologists per 100,000 population, according to the study first published online by Neurology in December 2020.

Telemedicine to the Rescue?

Telemedicine, especially during the pandemic, has helped make care more accessible in rural settings, but has not been a panacea. When COVID-19 emerged in early 2020, making in-person care unsafe, state and federal regulators relaxed the rules that had previously prohibited the widespread use of telemedicine. Concurrently, government and private payers began reimbursing care delivered by telemedicine to a greater degree than ever before.

As the severity of the pandemic waned, however, some support for telemedicine has fallen away. A few states rescinded pandemic-era rules that allowed physicians from other states to practice without a state-issued medical license, and some payers have tightened their payment policies for virtual care.

But Congress extended the federal public health emergency, which supports telemedicine, until September 14, and the nation's biggest payer—Medicare—is still paying for telemedicine visits in patient homes.

Regardless of the rules or reimbursement, telemedicine's promise to solve the rural neurology shortage looks limited, neurologists told Neurology Today.

“It does give access to people who are unable to come in,” said Thomas Buchanan, MD, a general neurologist and solo practitioner in Vernal, UT. “But as far as it being a boon or a breakthrough, that's not happening.”

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“My dementia patient population is probably where I've seen the biggest ongoing request for telemedicine visits, especially for patients and caregivers that may have to come from three or four hours away. Those long rides can be very challenging for the patient so, in those situations, I think it's a good fit.”—DR. MICHAEL STITZER

Dr. Buchanan started practicing in Vernal, a town of about 10,000 residents, seven years ago. The next closest neurologist works 115 miles away.

“When I first came out here, there were patients that had been having seizures for years and years and people who had been diagnosed with MS who were not on treatment,” he said. “It took a year or two to get through all of those patients that were not seeing any neurologist, but now I have this community well-served.”

On most days, he conducts three or four telemedicine visits, mostly for homebound patients for whom travel is difficult. But for most of his patients, telemedicine is not the go-to choice for neurology care.

One reason is limited broadband service in rural America, which makes maintaining an internet connection long enough for a physician visit a challenge. The other is that patients prefer in-person care.

“In rural medicine, there's a strong personal connection; people just want to see your face,” Dr. Buchanan said. “I have to actually encourage people to use telemedicine.”

He occasionally sees patients who have had telemedicine visits with neurologists in larger cities. “People don't like to be rushed, and telemedicine appears rushed to them, so they tend not to like it,” Dr. Buchanan said. “So, they may do telemedicine to get help with a question, but then they come to me and tell me what happened, and we'll figure out what to do.”

Michael Stitzer, MD, a neurologist at Winslow Indian Health Care Center in Arizona, shares Dr. Buchanan's perspective. Because there are few neurologists serving the Navajo Nation, about 50 percent of Dr. Stitzer's patients live beyond the Winslow area, with some coming from Utah and Nevada.

Telemedicine is a good option for some patients, but at this point, only about 10 to 15 percent of his patient encounters use the technology.

“My dementia patient population is probably where I've seen the biggest ongoing request for telemedicine visits, especially for patients and caregivers that may have to come from three or four hours away,” he said. “Those long rides can be very challenging for the patient so, in those situations, I think it's a good fit.”

Additionally, some patients prefer telemedicine to avoid the expense of traveling, especially since the price of gasoline has increased in recent months. “But a lot of patients do like being able to see a health care provider (in person) and to have an actual visit,” Dr. Stitzer said.

At the beginning of the pandemic, Dr. Stitzer and his colleagues at the health center tried to implement telemedicine for as many patient encounters as possible, but the lack of high-speed broadband Internet service made maintaining a good video connection difficult.

“We would always start with that for a visit, but then a lot of times that wouldn't work out so we would switch to the phone,” he said.

The early research on telemedicine adoption since the beginning of the pandemic seems to support the observations of Drs. Buchanan and Stitzer. After reviewing the key studies published to date, Neil A. Busis, MD, FAAN, professor of neurology at NYU Langone Health, found conflicting information about whether telemedicine is increasing health equity to rural and other traditionally underserved populations.

“This shows the need for better studies in this area,” Dr. Busis, chair of the AAN's Telehealth Subcommittee, said in an email. “There is no question the telehealth usage is way up, but more for primary care doctors than for specialists. Rural patients were relatively underserved, but ... it may have to do with preference and not with what we think of as the digital divide.”

The Challenge

Like many health systems, Spectrum Health serves a large rural population; Dr. Khan estimates that rural patients account for 30 to 40 percent of patients served by Spectrum's neurologists.

In his presentation at the AAN Annual Meeting, Dr. Khan discussed one of his patients, a man who lives one-and-a-half hours from Grand Rapids and has no car, no caregiver willing to drive him that far for medical appointments, and no internet access.

He had met the patient after a stroke required him to be admitted to a small-town hospital where Spectrum Health neurologists provide care via teleneurology. Dr. Khan wanted to provide follow-up care so he could review outpatient test results with the patient and discuss a care plan going forward. But the patient's circumstances presented a barrier to that care.

“That's where the issue came,” he said. “I challenged myself and my team: This is a real test of the health care system and us as neurologists. Can we provide care to this person, who does not have the ability to come to us and does not have the ability to connect through the internet?”

Eventually a solution was found: The patient traveled by bus to a rural regional hospital near his home, where Spectrum Health arranged access to the hospital's outpatient telemedicine cart, allowing Dr. Khan to provide follow-up care.

The experience prompted Dr. Khan to do a deep-dive into the disparities in health care access and outcomes for rural Americans. He sees the potential for telemedicine to be part of the solution but, like Dr. Buchanan and Dr. Stitzer, thinks that will require substantial investment and work in the years ahead.

“Telemedicine could be promoted better if we had improvement in the national infrastructure for internet access,” Dr. Buchanan said. “I think that there may be a gradual shift, but it is not happening quickly.”

Dr. Stitzer contends that telemedicine technology could increase rural patients' access to neurologic care through a hub-and-spoke model at rural clinics rather than trying to reach patients in their homes. A nurse practitioner or medical assistant at the clinic could help with the exam, directed by a neurologist connected via telemedicine.

“So, the patient is not just at home by themselves—and they can also have someone doing an exam and reporting those findings to the neurologist,” he said. “That also can cut out some of the difficulties with poor broadband because an (Indian Health Service) clinic will probably have better connectivity than the patient's home.”

Dr. Khan wants to see technology deployed to support collaboration between urban neurologists and rural primary care providers. “We as neurologists need to work more closely with primary care physicians so that we can educate them and work with them through electronic platforms or e-consult systems or audio calls to give them recommendations for their neurologic patients who are not able to come and see us,” he said.

Physician Leadership Is Needed

Nate Gladwell, senior director and clinical operations officer at the University of Utah Health, oversaw the explosion of outpatient telemedicine across several states at the height of the pandemic. Since then, virtual visits have declined; currently, they account for about 10 percent of visits.

Neurology is an outlier. “We're hanging at about 35 percent of all ambulatory visits are being done via telehealth,” he said. “That's a significantly high percentage, given the state of the pandemic.”

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“We as neurologists need to work more closely with primary care physicians so that we can educate them and work with them through electronic platforms or e-consult systems or audio calls to give them recommendations for their neurologic patients who are not able to come and see us.”—DR. MUHIB KAHN

University of Utah Health serves a heavily rural population. About 60 percent of its patients travel at least 100 miles to reach the main teaching hospital, and 30 percent come from another state.

Patient preference aside, Gladwell hopes physicians will embrace telemedicine as one solution to the neurologist shortage that hurts patients both urban and rural.

“There's no silver bullet to this—unfortunately, we're not printing neurologists, so the problem is only going to increase and intensify,” he said. “So, I hope all neurologists will help think through how to utilize virtual care as a tool to solve the access problem and not pooh-pooh it as second-rate medicine.”

He encourages neurologists to think of the patient with symptoms suggesting amyotrophic lateral sclerosis (ALS), for example, who must wait weeks or months for an appointment with a neurologist. “How can we use telehealth in the most appropriate ways so that we don't clog down a clinic with the 15th follow-up for a headache patient that needs to have a med refill?” he said. “How do we retain brick-and-mortar access for that newly diagnosed ALS patient?”

The Data on the Urban-Rural Divide in Neurology

A number of studies have demonstrated disparities in the distribution of neurologists in rural and urban areas. One study, presented in 2021 at the annual meeting of the American Heart Association, found that the density of neurologists in rural counties overall decreased from 6.3 to 5.9 per 100,000 population between 2010 and 2018. The analysis was conducted by health economist Sara Machado, a fellow in the department of health policy at the London School of Economics and Political Science, and three neurologists.

The study used the AMA Physician Masterfile data and a county-classification scheme developed by the Centers for Disease Control and Prevention to conduct their analysis. The research team found that, although most rural counties experienced little to no change in neurologist density during the study period, density increased in large metropolitan counties from 31.1 to 37.8 per 100,000 and in medium/small metropolitan counties from 29.3 to 32.2 per 100,000 during those years.

Meanwhile, the proportion of neurologists 44 years or younger appeared to increase in urban counties during the study period, while the proportion of neurologists aged 65 and older increased in rural counties during those years.

Link Up for More Information

• Chieh Lin C, Callaghan BC, Burke JF, et al. Geographic variation in neurologist density and neurologic care in the United States https://n.neurology.org/content/96/3/e309.long. Neurology 2020; Epub Dec 23.
• Predmore ZA, Roth E, Breslau J, et al. Assessment of patient preferences for telehealth in post–COVID-19 pandemic health care https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786700. JAMA Netw Open 2021;4(12):e2136405.
• Abrams LR, Myrskylä M, Mehta NK. The growing rural–urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death https://academic.oup.com/ije/article/50/6/1970/6348158?login=falseInt J Epidemiol 2021; 50(6):1970–1978.
• Cross SH, Califf RM, Warraich HJ. Rural-urban disparity in mortality in the US from 1999 to 2019 https://jamanetwork.com/journals/jama/fullarticle/2780628. JAMA 2021; 325(22):2312–2314.
• Hammond G, Luke AA, Elson L, et al. Urban-rural inequities in acute stroke care and in-hospital mortality https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.029318. Stroke 2020;7(51):2131–2138