Original Title: État des connaissances - Soins virtuels en neurologie

Authors' objectives: The aging of the population and the increasing prevalence of chronic diseases will, undoubtedly, lead to a significant increase in the demand for continuous home and institutional care, in the current context of limited professional resources in Québec. Furthermore, the COVID-19 pandemic has led to a major advance in the use of virtual care tools to ensure access to care and services and to promote the continuity of care. In addition to information technologies that are now frequently used, the integration of virtual care modalities into care pathways is of growing interest for the evaluation, treatment, and follow-up of patients in specialty medicine. Virtual care therefore has the potential to improve access to health care for most patients, but also to foster their engagement in the management of their illness. In the context of a national project on virtual care, the Ministère de la Santé et des Services sociaux (MSSS) has mandated the Institut national d'excellence en santé et en services sociaux (INESSS) to provide a state-of-knowledge report to guide the use of virtual care in specialty medicine. This work will help maintain or optimize care pathways and support clinical practices and the provision of care and services to patients. The objective of this work is to inform public decision-makers, medical associations, and health and social services professionals about virtual care practices in specialty medicine. The project involves the following seven reports: 1) Pediatrics, 2) Psychiatry, 3) Neurology (this report), 4) Hematology/Oncology, 5) Respirology, 6) General Surgery, and 7) Internal Medicine.

Authors' results and conclusions: RESULTS (#1 FINDINGS CONCERNING VIRTUAL CARE IN NEUROLOGY): Telerehabilitation is the intervention that has been studied the most in all the care pathways examined. • Most of the virtual care interventions identified in the different care pathways involve multiple modalities within a given review (e.g., telerehabilitation teleconsultation, telemonitoring and tele-education), and among these, the technologies employed also vary considerably. • A number of authors conclude that additional good-quality studies will be necessary. (#2.1: VIRTUAL CARE PATHWAYS REPORTED AS BEING CLINICALLY EFFECTIVE): For identifying and diagnosing mild and major neurocognitive disorders via teleconsultation, for individuals with various neurocognitive disorders in a favourable situation, e.g., caregivers present, acceptable level of disease severity, acceptable level of digital literacy, etc. • For improving cognitive functions − executive functions, verbal fluency, information processing speed and memory − through telerehabilitation via videoconferencing for those with various neurocognitive disorders. (#2.2: ASPECTS THAT NEED TO BE CLARIFIED BY FURTHER STUDIES): For improving certain motor functions (balance, walking and motor skills) through telerehabilitation for stroke victims. • For guiding the differential diagnosis of epilepsy through asynchronous teleconsultation by recording home videos, made by family members and shared with medical specialists, concerning people with seizures. (#3.1 VIRTUAL CARE MODALITIES FOR WHICH A POSITIVE IMPACT HAS BEEN REPORTED, SUCH AS): Teleconsultation adapted for physical, cognitive and social participation rehabilitation, which is the intervention mentioned most often, both for people with multiple sclerosis and for stroke victims. • Telerehabilitation, which is less frequently mentioned for movement disorders. • Asynchronous and synchronous teleconsultation, which is regularly mentioned for the assessment and treatment of individuals with movement disorders. • Synchronous teleconsultation, which is rarely mentioned for diagnosing headaches. (#3.2 VIRTUAL CARE MODALITY REPORTED AS HAVING A POTENTIALLY POSITIVE IMPACT ON ORGANIZATIONAL EFFICIENCY): Teleconsultation for patients with headache to reduce the length of initial and follow-up visits. (3.3 VIRTUAL CARE MODALITIES REPORTED AS HAVING A POTENTIALLY POSITIVE IMPACT ON THE CONTINUITY OF CARE AND SUPPORT FOR INTERDISCIPLINARY WORK): Teleconsultation and telemonitoring by automated or non-automated transmission of physiological parameters to ensure the continuity of care and services and to promote communication between the different health professionals responsible for monitoring and rehabilitating individuals with amyotrophic lateral sclerosis. (#3.4 A PROMISING LEVEL OF SATISFACTION, ALBEIT WITH CERTAIN CONCERNS): Patients and care providers generally express satisfaction with virtual care, particularly because of the flexibility, accessibility or easier care management. • Some patients express concerns about using virtual care, e.g., concerns about the technology, problems accessing equipment, feelings of frustration and fatigue. (3.5 FEW RESULTS ON THE SAFETY OF THE DIFFERENT VIRTUAL CARE MODALITIES OR ON PATIENT SAFETY): There are no reports of adverse events from virtual care for the assessment of patients with motor disorders. However, some studies warn against the risk of falls during remote rehabilitation sessions for stroke victims who do not have any assistance at home. • During virtual reality telerehabilitation sessions, the presence of a caregiver or health professional may be required to support the patient and ensure their safety. LIMITATIONS: This report is limited by the following methodological constraints: the type of documents selected, the literature review period of 5 years, the fact that independent study selection was used for only 10% of the studies, the absence of a formal evidence assessment, and the descriptive data synthesis with no meta-analysis. Most of the selected systematic reviews aggregate or select, without distinction, data from primary studies conducted in various care settings with a variety of comparators, clinical situations, and technologies. When meta-analyses are included, the heterogeneity of the studies and interventions, the small number of studies compared or the small number of participants, and the poor quality of the studies are often listed in the limitations. In addition, cultural sensitivity or cultural adaptation and collaborative care, which are topics that should not be overlooked for equity in virtual care, were very rarely discussed. Lastly, selection, confounding and measurement biases in the studies also need to be taken into consideration. For neurology, some authors also report that certain studies have followed patients for periods that do not reflect the duration of the required care and that it is therefore difficult to determine the long-term impact of virtual care for certain care pathways. CONCLUSION: In the field of neurology, the care pathway most studied in the literature for the use of virtual care is the diagnosis and rehabilitation of neurocognitive disorders. Teleconsultation is the modality most frequently employed in the care pathways studied. Virtual care in neurology generally seem promising for some care pathways, but the degree to which the patient is affected by the disease or condition may cause certain limits on the delivery of virtual care. In any event, the modalities are used alone or in combination with other modalities, and virtual care can be used in place of or in addition to standard care.

Authors' methods: A scoping review was conducted to portray the care pathways that might be supported or optimized with the use of virtual care. A review of the scientific and grey literature was carried out, the time period being the past 5 years. The existing national and international guidelines, guidance and discussion papers, and health technology assessment (HTA) reports published on the topic were also consulted to identify additional care pathways or to confirm those mentioned in the systematic reviews. Documents were selected according to predefined inclusion and exclusion criteria. These steps were carried out by one reviewer, and 10% of the titles and abstracts evaluated were independently reevaluated by a second reviewer. The literature selection process led to evidence extraction by a reviewer. The extracted data were analyzed and presented in the form of a narrative synthesis and tables for each care pathway identified. Because of the rapid nature of the work and the type of review conducted, the methodological quality of the selected documents was not assessed. In addition, the consistency of the study results, the number of studies and their perceived quality, the biases noted, and the statistical analyses of the meta-analyses were taken into account when drawing up the findings concerning care pathways and virtual care modalities that support or optimize clinical practices in specialty medicine. It is important to note that the acute treatment of stroke using virtual care, known as telestroke, was not evaluated in this report, as this pathway is already established in Québec.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Neurologie_EC.pdf

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Neurologie_EC.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)