Movement Disorder Specialists Survey Regarding Use of Telemedicine During the COVID-19 Pandemic

Introduction

Patients’ need for health services along with staff safety during the COVID-19 pandemic raised unforeseen changes in everyday medical practice. An increasing rate of mortality in health care workers, long-term delays in nonemergent outpatient services, and subsequent change of protocols in delivery of health care and services brought out the urgent and widespread use of teleneurology in clinical practice.^1–5 Tele-based communication is associated with a decrease in patient costs and decreased risk of infection in both providers and patients.^6,7 Also, neurologists anecdotally reported feasibility of virtual cognitive assessment in patients with epilepsy, headache, or multiple sclerosis, and higher chance of follow-up of patients with difficulties in commute or in-person contact (e.g., immunocompromised multiple sclerosis patients).

However, it can be associated with challenges in geriatric patients with movement impairments.^6–9 Movement disorder specialists might have a difficult time understanding, observing, and examining movement or neuropsychiatric symptoms. This leads to the need for the presence of care partners that could compromise patients’ privacy, increase patient stress, increase burden on the caregiver, and subsequently contribute to nonadherence of long-term therapy.

Limiting health care encounters to telemedicine, physical and mental health effects due to long-term quarantine, and possible development of new comorbidities among the elderly population with neurological conditions have all influenced the previous reports of satisfaction with the use of telemedicine for neurological diseases, both in patients and clinicians.^10,11 The satisfaction level of movement disorder specialists in using telemedicine is still unanswered, especially in a population who are dealing with geriatric patients with neurodegenerative conditions and often cognitive issues.¹²

The primary aim of this study was to assess the overall satisfaction level of movement disorder specialists using a virtual platform during the COVID-19 pandemic. The secondary aim was to compare the level of care, convenience, and overall satisfaction between movement disorder and nonmovement disorder physicians.

Methods

ETHICS

The Office for Civil Rights at the Department of Health and Human Services allowed clinicians to apply remote health services as an alternative to traditional in-person visits under the policies of Health Insurance and Portability and Accountability Act.¹³ The protocol of the study was exempted from institutional review board evaluation as it was a quality improvement report to assess physician satisfaction with delivery of health care through telemedicine.¹⁴

STUDY DESIGN

This was a multicenter cross-sectional survey for a 6-month period during the beginning of the COVID-19 pandemic. The patient encounters were randomly selected from four large movement disorder centers around the country, at the University of Kansas Medical Center (Kansas City, KS), the Parkinson’s Disease and Movement Disorder Center of Boca Raton (Boca Raton, FL), Saint Charles Hospital (Commack, NY), and Georgetown University Hospital Movements Disorders Center (Washington, DC), and nonmovement disorder clinics at the University of Kansas Medical Center.

Neurologists, who utilized telehealth visits from March 2020 to August 2020, were included. Providers were categorized as movement disorder specialists and nonmovement disorder specialists. Telecommunication was implemented using the following software/systems: Emergency Medical Responder, Zoom, Doximity Dialer Video, Doxy, or telephone call.

Before each telehealth visit, assistants evaluated the feasibility of a remote visit for each patient through phone call and made sure that the patient had the necessary hardware and software available before the telehealth visit. The study surveys were completed by the provider after the visit.

The survey questionnaire included the following questions: patient’s age, primary diagnosis, software used, whether backup was used, presence of connectivity problems and when present length of time that the visit was prolonged, time spent with the provider, provider’s satisfaction with the technical quality of connection, provider’s satisfaction with the quality of the visit, whether a caregiver was present at the visit, whether a caregiver routinely accompanies patient, whether and why a caregiver was essential for the visit, whether any medication changes were recommended, provider’s satisfaction with the care that they were able to provide, provider’s satisfaction with the convenience compared with in-person clinic visit, and provider’s overall satisfaction with the visit.

ANALYSIS

Data were entered into SPSS software version 26. The percentages of categorical data were compared between movement and nonmovement patients using chi-square test. Mann–Whitney test was used to compare the mean Likert scales between the two groups. Respondents were asked to rate the questions as: very satisfied = 1, satisfied = 2, neutral = 3, unsatisfied = 4, or very unsatisfied = 5. Analysis of variance was used to compare the means between categorical independent variables. Possible significant differences between the means were specified using post hoc tests. Correlations between the means were also calculated. Significance level was considered <0.05.

Results

A total of 270 visits with the mean patients’ age of 67.8 ± 14.5 were analyzed. Of those patients, 206 with the mean age of 72.7 ± 10.7 years were seen by movement disorder specialists and 64 with the mean age of 51.7 ± 13.4 were evaluated by nonmovement disorder neurologists. In the movement disorders group, Parkinson’s disease (PD) was the most common diagnosis among patients (168, 81.6%) and other movement disorder diagnoses included essential tremor, parkinsonism, dystonia, Huntington disease, restless leg syndrome, dementia, Tourette syndrome, and indeterminate tremor.

Movement disorders patients with deep brain stimulators (DBS) accounted for 11 (5.3%) encounters, and personal kinetic graph reports were analyzed in 8 (3.9%) encounters. Zoom was the most popular platform for telemedicine used by movement disorder specialists for remote visits (70, 34%). A backup platform was not needed in the majority of movement disorders visits (171, 83%). Connectivity problems happened in 54 (26.2%) encounters and were not significantly different from the nonmovement disorder visits. Of the patients who experienced connectivity problems, the majority of encounters were prolonged by <15 min (20%). Movement disorder specialists most often spent between 15 and 24 min for visiting the patients (71, 34.5%).

During the virtual visit, medicine was adjusted or changed in 143 (69.4%) movement disorder patients. Medication adjustments were delayed or deferred in three patients (1.5%) during their virtual visit. The caregiver looked after the movement disorder patient routinely in 124 (60.2%) cases. Providers felt that in the case of 71 (34.4%) patients, the caregiver was imperative because of cognitive or other disability issues, though about half of the patients (110, 53.4%) were accompanied by a caregiver. Of those patient encounters when the caregiver was felt to be imperative for a successful visit, 62 (87.3%) of those patients had the caregiver present during the virtual encounter. Connection quality, visit quality, care satisfaction, convenience, and overall satisfaction were not significantly different between the visits accompanied by a third party (e.g., caregiver) and those visits without a third party.

The primary aim of the study examined the level of satisfaction of the telemedicine encounter in movement disorder specialists (Table 1). The majority of movement disorder specialists were very satisfied or satisfied with the care provided (72.9%) and visit quality (61%). Physicians were also very satisfied or satisfied with the convenience provided by the use of virtual visits in 144 (70%) encounters. Providers’ overall satisfaction was very satisfied or satisfied in 129 (62.2%) of encounters.

The secondary aim of the study compared the providers’ satisfaction level with the encounter between movement disorder patients (206, 76.3%) and nonmovement disorder patients (64, 23.7%). There were significant differences between the mean satisfaction overall and more specifically, for connection quality and visit quality, in the two groups (all better for movement disorder visits, Table 2). In movement and nonmovement groups, the mean age was not different between patients with different visit durations (p > 0.05).

The exploratory aim of the study investigated the correlations between different satisfaction scales in all physicians that are presented in Table 3.

Discussion

This study investigated provider satisfaction level among movement disorder specialists regarding clinical encounters using a virtual platform during the COVID-19 pandemic. Although the elderly population has been considered less interested in telecommunication, the mean age of movement disorder patients seen by our specialists demonstrates that video-based visits are feasible with elderly patients.¹⁵ Most of the visits, either in patients with movement or nonmovement disorders, were accomplished without any connectivity problems. This was a remarkable finding in an elderly population with potential cognitive impairment or decreased technology literacy, who are assumed to require a third party to participate.

However, just under half of patients were not accompanied by a third party. In the case of encounters that had a technical issue requiring a change in the platform or a backup plan, it did not lead to a prolonged visit or provider dissatisfaction in most of the visits. This suggests that telemedicine can be conveniently delivered and coordinated by movement disorder specialists so that patients can be efficiently treated.

The high number of encounters with recommendations for therapeutic intervention means that the encounter was successful in providing enough information to make a therapeutic decision. There were cases when the virtual environment had no effect on the decision to start or adjust the medications. In contrast, there were still some encounters that resulted in no therapeutic changes due to patient reluctance to adjust or start a medication in the setting of the pandemic. One center was concerned in starting or adjusting medication in case a medical complication requiring the need for urgent in-person medical care occurred. The need to isolate, to mitigate the spread of COVID-19, may have played a role in both the provider and patient decision making for whether or not to start new or adjust current medications.

It is conceivable that once the need to isolate is gone, there may be no difference between virtual or in-person visits with regard to starting or adjusting medications. In other words, doctors and patients would make the same decision regarding therapeutic intervention regardless of the type of encounter given that there would be no risk to leaving home and seeking urgent care in the event of an adverse effect. In comparison with nonmovement patients, feasibility of changing or adjusting medications virtually in movement disorder patients seemed higher.¹⁶

Regarding the primary aim of the study, the satisfaction level of movement disorders specialists using a virtual platform during the COVID-19 pandemic was favorable with most clinicians, who were very satisfied with all domains of satisfaction including connection quality, visit quality, care provided, convenience, and overall satisfaction (Table 1). Our findings are in agreement with most of the previous studies.¹⁷ The high level of satisfaction may make providers more likely to utilize telemedicine more frequently in the future, allowing for shorter follow-up intervals and increased convenience for those traveling a great distance to in-person visits.

In fact, movement disorders may be better suited for more frequent care that virtual visits provide. Also, the technology offers a possibility to confirm a clinical suspicion with video, such as is the case for distinguishing between a tremor and dyskinesia. With telemedicine, movement specialists can evaluate the movements using a modified Unified Parkinson’s Disease Rating Scale and motor examination to better titrate and adjust medications.

Analyses regarding the secondary aim of the study provided a comparison between the level of care, convenience, and overall satisfaction of encounters between nonmovement disorder patients and those of movement disorder patients (Table 2). Connection quality, visit quality, and overall satisfaction were significantly better in movement disorder visits. In this study, most of the nonmovement patients presented with cognitive or memory problems. It shows that cognitive and memory problems may contribute to the lower levels of satisfaction in physicians. Since previous studies examining the clinician’s satisfaction with encounters with patients with cognitive impairment have reported different levels of satisfaction, more studies are recommended regarding the influence of cognitive impairment on implementation of telemedicine.^18–20

Surprisingly, the overall satisfaction level of specialists was positively correlated with age, with the connection quality satisfaction of providers decreasing in elderly individuals (Table 3). Previous studies about the satisfaction level of clinicians in movement disorders and the correlation with patients’ age are limited.

In this study, most of the providers spent >15 min on the encounter with the patients. This could be attributed to additional time needed to train and accommodate the patients and longer duration of neurological and cognitive examination. However, most of the providers were satisfied with telecommunication, implying successful adaptation of movement disorders specialists to telemedicine during the COVID-19 pandemic. Per previous studies, it was estimated that of 121 min required to visit a health care provider, only 15–20 min was spent with a physician and the remaining time was spent traveling to the care center and sitting in a waiting room.

Our finding that most visits were between 15 and 39 min suggests that telemedicine can take less time and effort for the patient and caregiver per clinical encounter with increased interaction with the provider. Telemedicine has played a successful role in assessing the visual aspects of physical examination in movement disorders that can improve the satisfaction in both patients and clinicians.^21–23

Our study investigated provider satisfaction level of movement disorder specialists from four large movement disorder centers around the United States. Results of this study can help inform how we can apply telehealth wisely, demonstrating how rapid adoption of telehealth during a crisis can provide increased opportunities for learning and adding evidence to a growing body of literature.

This study has some limitations. First, this is a cross-sectional study design, lacking a comparison group. Future studies with a comparison group utilizing phone-based calls and/or in-person visits to compare satisfaction would be needed to draw comparisons between the visit modalities. In addition, only some patients were evaluated by assistants for the feasibility of remote visit through phone call and, if qualified, provided with stepwise training to facilitate access to the video-based visits.

Future studies can be done to observe improvement in provider satisfaction by providing patient assistance before all visits. Second, there were very limited data about programming visits for DBS and the carbidopa/levodopa enteral suspension pump. This study would require another study to collect data to analyze these specific types of visits. Third, this study only sought to examine clinicians’ perception and satisfaction of the telemedicine visits and did not collect data from patients on their experiences with telemedicine.

Elderly patients with many comorbidities might need to visit several different specialists with short intervals that can affect the medication and follow-up adherence. However, high level of satisfaction may make providers more likely to utilize this means of patient encounter more frequently in the future, allowing for shorter follow-up intervals. Cognitive status can affect a patient’s ability to use telemedicine, and this might raise the need for a third party, affecting the visit quality. Further studies regarding the influence of severity of the disease, cognitive status, comorbidities, and other PD outcomes on the satisfaction of telemedicine are highly recommended.

Conclusions

Telemedicine has opened a new window for movement disorders specialists to interact with patients along with reduced risk of human exposure and uncontrolled spread of COVID-19. The satisfaction level of specialists using telemedicine during COVID-19 was high despite having encounters with elderly patients with cognitive impairment or lacking advanced knowledge or skills with technology.

Authors’ Contributions

S.G. contributed to design of the study, acquisition of data, analysis and interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted. Y.A.T.-Y. contributed to design of the study, acquisition of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted. S.H.I. and F.P. were involved in conception and design of the study, revising the article critically for important intellectual content, and final approval of the version to be submitted.

K.E.L. carried out conception and design of the study, acquisition of data, interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted. B.J.N. and S.P. were involved in interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted. R.P. contributed to conception and design of the study, designing the questionnaires, acquisition of data, interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be submitted.

Disclosure Statement

All authors have confirmed their contribution to this study. None of the authors had any conflict of interests or financial ties to disclose.

Funding Information

No funding was received for this study.