Telemedicine vs Clinic Visits for Patients with Parkinson’s Disease
Abstract & Commentary
By Claire Henchcliffe, MD, PhD, Associate Professor of Neurology and Neuroscience, Weill Cornell Medical College. Dr. Henchcliffe reports she is on the speakers bureau and advisory board for Allergan and Teva; speakers bureau for Boehringer-Ingelheim, GlaxoSmith-Kline, and Novartis; advisory board for Merz; and is a consultant for Gerson Lehman Group and Guidepoint Global.
Synopsis: This randomized, controlled trial compared outcomes in patients with Parkinson’s disease who received follow-up neurologic care from home via a web-based teleconferencing system vs in-person visits in a neurology clinic. Results support the potential use of telemedicine in the treatment of Parkinson’s disease.
Source: Dorsey ER, et al. Randomized controlled clinical trial of “virtual house calls” for Parkinson’s disease. JAMA Neurol 2013;70:565-570.
The primary objective of this study was to evaluate the feasibility of the use of telemedicine for providing specialty care to patients with Parkinson’s disease (PD) in their homes. Secondary outcomes included clinical benefit to patients as well as economic value compared with patients who received in-person care from a specialist. Patients were recruited from two academic centers and randomized in a 1:1 allocation to receive care via web-based teleconferencing in their homes or in-person visits with a specialist. Twenty patients with a clinical diagnosis of PD were recruited, with 11 (mean age 64.5 years, 27% female) randomized to receive in-person care and nine (mean age 66.6 years, 22% female) assigned to the telemedicine group. Feasibility was measured by the percentage of visits completed as scheduled, the proportion of visits completed by each group, as well as the number of in-person visits required by patients assigned to the telemedicine group. Secondary outcome of clinical benefit was measured by changes in the Parkinson’s Disease Questionnaire (PDQ-39) and Unified Parkinson’s Disease Rating Scale (UPDRS) items I to III (rigidity and postural stability were not assessed). Patients at one site completed the Patient Assessment of Care for Chronic Conditions (PACIC). Assessments were made at baseline (prior to randomization) and at three visits over 7 months (months 1, 4, and 7). Ninety-three percent of telemedicine visits were completed and 91% of in-person visits were completed. No patient assigned to the telemedicine group required an in-person visit during the study. The changes in PDQ-39, UPDRS, and PACIC did not differ between the two groups. Participants spent an average of 53 minutes devoted to a tele-medicine visit (time from computer on to computer off) vs 255 minutes for an in-person visit (time from leaving home to return). The amount of time spent with the physician did not differ significantly between the two groups but the amount of visit time spent without the physician was much lower for the telemedicine group (18 minutes vs 207 minutes; P < 0.001).
Commentary
Access to neurologic care and specialty care may be limited in people with PD for multiple reasons, including PD effects on mobility as well as geographic factors. The use of telemedicine in the care of PD patients would seem to be a logical technique to improve patient care, and this innovative study supports the feasibility of this approach. The small number of participants makes detection of meaningful differences in outcomes difficult, and the results presented warrant a much larger study. However, the differences in time spent to accomplish a visit strongly suggest seriously considering use of a telemedicine approach. Moreover, with advancing technology that allows remote data capture, there is a strong case for reconsidering the traditional approach of limiting care to office visits in chronic disease. Unfortunately, in the current health care system there are many practical and legal questions concerning telemedicine that will need to be answered before its use expands out of the research arena. How will telemedicine visits be reimbursed? Can patients be assessed adequately and safely via the Internet? What are the legal implications and liability for making decisions and recommendations without physically examining the patient? Having said this, it is an exciting possibility that telemedicine may have a valuable role in patient care in the future. Telemedicine visits could be used in conjunction with in-person office visits to expand patient access to care and to lower costs. The current study therefore supports the feasibility of web-based videoconferencing, and strongly suggests the need for larger, multicenter studies to further explore this approach in the management of complex, chronic diseases.