ABSTRACT
Background: Utilization of teleneurology for MS care rapidly expanded during the COVID-19 pandemic to maintain healthcare access. Disparities in telehealth use have been described in other health conditions, but not in a MS population. Objectives/Aims: To evaluate longitudinal utilization of teleneurology across age, race, geographic factors, and insurance categories to identify potential disparities in utilization at a single academic MS center (Cleveland Clinic). Method(s): MS patients attending a specialty clinic in Cleveland, a medium-sized city, who completed >=2 visits at least 24 months apart from 1/2019 to 6/2021 were studied. Patients with fully inperson care were compared to patients with <50% or >50% teleneurology care. Categories of age, race, geographic factors, and insurance were compared using Kruskal-Wallis tests and pairwise Wilcoxon rank sum tests with Bonferroni correction for multiple comparisons. Result(s): 892 patients met the inclusion criteria and completed 3710 visits during the study timeframe: mean age 49.1+/-11.7 years, 73.7% female, 85.6% white, median disease duration 11.2 years [0.15;60.3], and relapsing-remitting 62.3%. 37% patients were fully in-person, 37.2% patients had <50% teleneurology care, and 25.8% patients had >50% teleneurology care. There were no significant differences for race (white, black, other), insurance type (Medicare, Medicaid, private, non/other), area deprivation index (ADI), and residence location (rural vs metropolitan) in the use of teleneurology. Use of teleneurology care varied based by age, with older patients utilizing more in-person care. In person care was 23.4% for ages 18-39, 38.5% for ages 40-60, and 47.8% for those greater than 60 (p<0.001). Patients residing in greater Cleveland had significantly more in-person care (55.3%) compared to residents residing in Ohio outside of the greater Cleveland area (34.7%) and outside of Ohio (10.1%) (p=0.031). Conclusion(s): There were no significant differences in teleneurology utilization across race, insurance, ADI or rural vs metropolitan residence, suggesting it is a broadly accessible tool to overcome disparities in access to MS care. Utilization of teleneurology care for older and local patients was lower, which may be due to decrease demand in these groups. Future studies should assess the optimal integration of teleneurology and in-person visits in MS management.
ABSTRACT
Introduction: The approval of ocrelizumab (OCR) for the treatment of primary progressive MS (PPMS) showed that the course of progressive MS (PMS) can be altered with effective treatment;however, direct evidence across the spectrum of PMS, including secondary progressive MS (SPMS), is still lacking. Objective(s): CONSONANCE (NCT03523858) is a single-arm, phase 3b, 4-year study designed to evaluate for the first time the effectiveness and safety of OCR in patients with SPMS or PPMS. Year 2 results are reported. Method(s): Patients with active or non-active PMS but showing disability progression in the past 2 years were enrolled. Primary outcomes are (1) proportion of patients with no evidence of progression (NEP) defined as no progression confirmed for >=24 weeks on Expanded Disability Status Scale (EDSS), no >=20% increase in timed 25-foot walk test (T25FWT), no >=20% increase in nine-hole peg test (9HPT) time, and no MS-related death or treatment discontinuation due to efficacy failure;(2) proportion of patients with no evidence of progression and no active disease (NEPAD) defined as NEP plus no protocol-defined relapse, no new/enlarging T2 lesions (N/E-T2, re-baselined at week 24), and no T1 gadolinium-enhanced lesions. Result(s): Patients (n=629;SPMS n=324, PPMS n=305) had mean (SD) age of 48.5 (9.2) years and 52.3% were female. At baseline (BL), median (IQR)/mean (SD) EDSS scores were 6.0 (4.5- 6.0)/5.3 (1.3) for patients with SPMS and 5.0 (4.0-6.0)/4.8 (1.3) for PPMS. Overall median times for 9HPT and T25FWT were 27.9 and 9.4 seconds, respectively. Over 2 years, 311/586 (53.1%) patients had NEP (SPMS 55.8%;PPMS 50.2%;progression was mostly driven by increases in T25FWT) and 283/588 (48.1%) had NEPAD (SPMS 49.5%;PPMS 46.7%;acute activity predominantly driven by N/E-T2 lesions). Overall EDSS remained stable from BL to year 2 (mean [SD] change of +0.07 (0.79) points). In patients with EDSS >=2.0 at BL (n=526), 24-week confirmed disability improvement in any of the components (EDSS, T25FWT, 9HPT) was observed in 29.8% of cases. Rates of serious AEs and serious infections were 7.6/100PY and 3.2/100PY, respectively. Eight deaths were reported (COVID=6, pulmonary embolism=1, non-small cell lung cancer=1). Conclusion(s): Over a 2-year period, treatment with OCR was associated with comparable rates of NEP and NEPAD in patients with SPMS and PPMS, and with functional improvement in about one-third of patients. Safety outcomes were consistent with known safety profile.
ABSTRACT
Background: Utilization of teleneurology rapidly expanded during the COVID-19 pandemic for multiple sclerosis (MS) care to maintain healthcare access. Feasibility and high patient satisfaction with virtual care has been studied, but there are no data regarding the impact of teleneurology on clinical outcomes. Objectives/Aims: To examine the impact of teleneurology care on MS outcomes at a single academic MS center (Cleveland Clinic). Methods: MS patients who completed ≥2 in-person visits 12 months apart (+/- 6 months) from 1/2019 to 12/2020 were studied. Patients with fully in-person care were compared to patients with a combination of teleneurology and in-person care during this timeframe. Multiple linear regression models were created to assess differences in clinical outcomes between groups, adjusting for age, sex, race, employment status, disease duration, education, MS course (relapsing remitting (RRMS), progressive), disability level measured by Patient Determined Disease Steps (PDDS), number of visits, and time from baseline. Significance was set at p<0.05. Results: For 2131 patients meeting the inclusion criteria: median time between the first and last in-person visits 366 days, mean age 49.5±12.6 years, 72.4% female, 81.4% white, 55.3% employed, disease duration 15.9±11.5, RRMS 58.5%, and 71.2% PDDS <=4, distance from center 65.3 [22.9, 409] ). 1905 (89.4%) had only in-person visits and 226 (10.6%) had both teleneurology and in-person visits. The teleneurology group had shorter disease duration (14.4±10.3 vs 16.1±11.6 years), higher disability score (32.3% vs 25.1% PDDS >4), greater interval between first and last visit (412 [367, 497] vs 363 [253, 424] days), lived closer to the center (34.8 [17.3, 83.0] vs 68.9 [23.3, 2081] miles), and higher total number of visits (4 [3, 4] vs 3 [2, 3] visits) (p<0.05 for all). The groups did not differ for age, sex, race, employment status, education, or MS course (p>0.05). Patients with teleneurology care had no significant difference in manual dexterity, processing speed, or walking speed compared to patients with only in-person care after adjustment for demographic and disease characteristics (p>0.05 for all). Conclusions: This study demonstrates that teleneurology care did not appear to have an effect on clinical outcomes in MS. These data support the continued use of teleneurology in MS care. Future studies are needed to elucidate the optimal combination of teleneurology and in-person visit types for MS patients.
ABSTRACT
Objective: Determine the effect of COVID-19 on telemedicine access for racial minorities prior to, during and following the COVID-19 surge at the Cleveland Clinic Headache Section. Background: Racial, ethnic and socioeconomic minority patients face significant barriers to receiving equal access to health care. Telemedicine has the potential to increase access to specialty medical care among the urban underserved. We seek to understand the effects of rapid implementation of telehealth across different racial subgroups during the COVID-19 pandemic. Design/Methods: We conducted a retrospective data review of patient visits at Cleveland Clinic Headache Section during the following time points: January 1 - March 13, 2020 (control - prior to COVID-19 pandemic surge), March 16, 2020 - May 22, 2020 (COVID-19 surge) and May 26, 2020 - August 20, 2020 (post COVID-19 surge) in 2020. We compared demographic data (age, sex, race, and marital status). Results: Pre COVID-19 pandemic surge included 380 virtual visits of which, 339 (89%) were white and 18 (4.7%) were identified as BIPOC (black, indigenous people of color). In-person visit group included 1890 patients with 1426 white (75%) and 365 (19%) identified as BIPOC. During the COVID surge, there were 1797 virtual visits with 1423 (79% white) and 303 (17%) BIPOC. The post COVID-19 surge had 1801 virtual patients with 1472 (82% white) and 256 (14%) BIPOC. In person group had 805 patients with 582 white (72%) white and 187 (23%) BIPOC. Conclusions: Pre-COVID-19 pandemic there was proportionally less usage of virtual visits by minorities compared to whites. It was unclear if such groups would have the same access to virtual care. However, during COVID-19 surge we saw a slight increase in virtual visits by minority groups which continued post COVID-19 surge when in person visits began. We also saw an overall slight increase in healthcare utilization by this minority group.