Neurologists around the country—from migraine specialists to epileptologists—are overhauling the way they deliver their patient care during the COVID-19 outbreak, mostly transitioning from face-to-face visits to video or telephone visits. They also face decisions on which circumstances require an in-person visit with a physician, or a trip to the hospital, despite the infection risk from the novel coronavirus.
The sudden change has been prompted by recommendations—and now, in many states, outright orders—to maintain social distance. These mandates are more financially feasible for neurologists with the decision by the Centers for Medicare and Medicaid Services to make telemedicine visits reimbursable across the country, not just in designated rural areas with limited access to care.
"What we've been asked to do is categorize who must be seen in person, who could do a phone call and who could do telemedicine," said Jennifer Bickel, MD, FAAN, chief of the headache section at Children's Mercy Hospital in Kansas City. "Suddenly one of the risks of doing the procedure is no longer the typical risk versus benefit of doing the nerve block. Now it is the risk of obtaining the virus. Suddenly, everything needs to be weighed differently because now there is risk for fatality in inpatient visits, which was not something we had before."
Dr. Bickel said that the default is that all migraine cases, for instance, are to be done by telemedicine and not treated with procedures requiring a physical visit. But she added that decisions are made on a case-by-case basis.
She said that if a child's headaches becomes severe because they're not getting a procedure—such as Botox or a nerve block—and they are a proven strong responder to that procedure, then they can come in during specific periods that are available for in-person visits.
"It's not that we've said, 'Absolutely never,'" she said. "With no clear algorithms for first-, second- and third-line treatments for pediatric migraine, physicians are now more likely to attempt a treatment for patients that don't involve a physical procedure, she added.
"It gives us an opportunity for somebody, who instead of getting"— for example "Botox, that we put them on one of the new CGRP [calcitonin gene-related peptide] antibodies instead," Dr. Bickel said.
Jacqueline A. French, MD, FAAN, professor of neurology at the NYU Langone Comprehensive Epilepsy Center, said that the vast majority of patient visits are now being done over the phone or with video.
Cautioning that the situation changes by the day, she said that, as of the last full week of March, a priority was to keep patients out of the emergency room as much as possible, sometimes even if they have a convulsive seizure. For example, previously, if a patient who'd been doing well for a year had a breakthrough seizure, they might be told to visit the emergency room largely for their own reassurance, because it is such a distressing, traumatic event.
"You would not send those patients anymore," Dr. French said. Electroencephalograms that used to be easy to obtain in the ED are no longer easy to obtain, and it might be considerably easier to get labs at an outpatient lab center, she said.
As for routine follow-up visits, much of the examination and interaction can be accomplished with telemedicine, she said. On top of that, patients prefer not having to come in to an office where they might be exposed to an infection.
Still, there are times when an in-person visit is needed, she said. Someone with a new symptom who needs a more detailed neurologic exam to see whether there is a new problem might fit into that category, she said. A patient with a vagus nerve stimulator or responsive neurostimulator who needs an adjustment to the device previously would also have had to physically visit the clinic—but in many centers these are now put on hold until it is safer to return to clinics. These adjustments should only be done when they cannot wait, and this is rare, she said.
"We all do risk-benefit in our heads for everything all the time, so I think that in general we are not at this point feeling like we are giving inferior care to people," Dr. French said. "So that's reassuring."
James C. Grotta, MD, FAAN, director of the Mobile Stroke Unit Consortium at the Memorial Hermann Texas Medical Center, said that nearly all visits except active stroke or transient ischemic attack have been transitioned to telephone or video visits. That will usually be enough to take stock of what is going on, he said.
"If it's an issue where someone thinks their speaking is worse, or their hemiparesis is worse, we can see that easily on Facetime, and by telemedicine," he said.
Up until now, far more people have strokes than are becoming seriously sick with COVID-19, and stroke patients have no choice but to get to the hospital, where their exposure risk is high.
"The acute strokes are not decreasing in number—we still have them and we still have to take care of them and we're doing that more or less the same way," he said. "The main thing we're trying to do is to separate the COVID patients as they come in."
Those who do need to be hospitalized are having their stays shortened as much as possible, he said.
"For stroke patients, a lot of times we'll get tests after 24 hours like echocardiograms and follow-up MRI scans and things like that," he said. "A lot of that is being deferred and being done as an outpatient to shorten the hospitalization."
On March 30, the American Heart Association/American Stroke Association (AHA/ASA) published in its journal, Stroke, what it termed "temporary emergency guidance to US stroke Centers" for addressing COVID-19.
The AHA/ASA recommended, among other suggestions, that clinicians continue to treat stroke patients as appropriate; seek ways to minimize the use of scarce personal protective equipment, sending the fewest possible team members to see "code stroke" patients; and use telemedicine or televideo, whenever possible.
In its guideline, the AHA/ASA stressed that these recommendations have not been submitted through its normal guideline development and peer-review process, and that the AHA/ASA will begin the process immediately and continue to update the statement continuously through the COVID pandemic.
Patients at the Northwestern University multiple sclerosis clinic are being seen almost entirely via telemedicine, said Bruce A. Cohen, MD, FAAN, the chief of MS and neuroimmunology there. The exceptions, he said, are people who have an active symptom that has to be evaluated, and those who need to come to the infusion center for their treatment.
"If somebody were reporting a significant change in function where we're trying to figure out if they have a relapse or not—as opposed to perhaps a pseudo-relapse—we might see that patient rather than try and treat them over the phone. But those are relatively few," he said.
The dominant theme of the calls has been how a possible COVID infection interacts with MS and the patient's treatment regimen, and physicians are able to keep them updated on this through telemedicine, he said.
"The main thing we're trying to do is keep people out of emergency rooms and limit potential exposures to COVID-19," Dr. Cohen said.
Neil S. Lava, MD, FAAN, co-director of the Comprehensive Multiple Sclerosis Clinic at Emory University, said that the transition has been similar at his center.
"There are some patients who have acute onset of neurological symptoms where we're concerned and we have to see them," he said.
Dr. Lava said there is one physician at the clinic every day in the event that a patient didn't get the message that their in-person visit was canceled, or if someone truly needs to be seen in person. Otherwise, everyone is being seen through Zoom or by way of phone calls.
"For a lot of these people, they're already on medication, they're sort of stable so we can handle things through telemedicine," he said. "It is reassuring and comforting for them to be able to communicate that way."
Link Up for More Information:
Lyden P, et al. Temporary emergency guidance to US stroke centers during the COVID-19 pandemic on behalf of the AHA/ASA Stroke Council Leadership. Stroke 2020; Epub 2020 Mar 30.