Contribution of a synchronic teleneurology program to decrease the patient number waiting for a first consultation and their waiting time in Chile

For this retrospective cohort study, we analyzed data from patients referred to the HHT Neurology clinic, between January 2013 and December 2018, whether consulting in situ at the HHT or enrolled in the Teleneurology Program. Patients were referred from the following primary health facilities of the Public Health System: i) Community Family Health Centers (CECOFS for the Spanish acronym) 8 de Mayo, Cerro Estanque, Cosmito, El Santo, Esmeralda, España, Forjadores, Govinden, Libertad Gaete, Llafkelén, Los Lobos, Parque Central, Punta Parra, Rene Schneider, and Ríos de Chile, and ii) Family Health Centers (CESFAM for the Spanish acronym) Alberto Reyes, Bellavista, Hualpencillo, La Floresta, Leocan Portus, Lirquén, Los Cerros, Paulina Avendaño, Penco, San Vicente, Talcahuano Sur, and Posta Dichato. Patients were also referred by a secondary health center (Mental Health Center, COSAM for the Spanish acronym) Hualpén and the tertiary health centers: HHT, Tomé Hospital, Penco-Lirquén Hospital, with the latter ending its participation in the program in 2018 (Additional file 1). Details of the modality of synchronous care of the Teleneurology consultation and the inclusion and exclusion criteria of the patients included in this study were previously described by Constanzo et al. [15].

Main outcomes analyzed were:

Independent variables analyzed were: i) age (60<, and > =60), ii) gender (male or female), iii) referral healthcare facility (primary, secondary, or tertiary), and iv) type of appointment (in situ at HHT or by telepresence through the Teleneurology Program). Finally, patients unnecessarily referrals come from patients referred to general practitioner for face-to-face attention in the HHT. These patients are registered in the system as poorly derived.

The HHT Neurology Unit consists of 11 neurologists and two general practitioners. The neurologist group dedicate, as a group, 74 h per week to consultation in situ at HHT and 17 h per week to the Teleneurology Program. The general practitioners dedicate, as a group, 21 h per week for: i) coordination of care and follow-up of patients waiting for an appointment, ii) extension of chronic patient prescriptions, iii) follow-up of patients with a prolonged medical license or in the process of requesting disability pension. This allows the team of neurologists to focus exclusively on the resolution of patients’ neurological problems.

This study analyzed retrospectively a cohort of 8269 adult outpatients who obtained their first appointment with a neurologist at the Neurology clinic of the Hospital Las Higueras de Talcahuano (HHT), between January 2013 and December 2018. Out of the total, 6526 patients (79%) consulted the specialist in situ at HHT and 1743 (21%) had their appointment with the telepresence of the neurologist, through the Teleneurology Program at HHT. As summarized, 2829 patients (34%) were male, while 5440 (66%) were female (Table 1). similar gender distribution percentages resulted after sorting patients in terms of the type of appointment (in situ or by telepresence).

On the other hand, 1382 (17%) patients were between 15 and 30 years of age, 946 (11%) were between 31 and 45 years old, 1823 (22%) were 46 and 60 years of age, and 4118 (50%) were over 60 years old. Similar age distribution was observed when grouping patients according to their type of appointment.

Finally, In situ neurologist attention at the HHT referred 3411 (52%) patients from primary health facilities, 42 (1%) from secondary health services, and 3073 (47%) from tertiary health care centers. The Teleneurology Program referred 1591 patients (91%) were from primary centers, and 152 (9%) from tertiary facilities, with no patients being referred from secondary services (Table 1).

The Neurology clinic at HHT began the follow up of patients waiting for a first appointment with a specialist in March 2015. Table 2 shows the time course of the number of patients in this “waiting list” (for the Spanish legal term “lista de espera”) from March 2015 until December 2018. Out of the total 3084 patients waiting by March 2015, 743 (24%) were since 2013, 1740 (56%) since 2014, and 611 (20%) since the beginning of 2015. By December 2018, only 298 patients (90% lower than those in March 2015) were waiting for their appointment: 68 (23%) waiting since 2017 and 230 (80%) from 2018 (Table 2). Unfortunately, the patients from 2017 could be reached by the health service. Interestingly in certain cases, patients were unnecessarily referred to the Neurology clinic, due to misclassification of the symptoms. The clinic registry of declares declines from 105 patients referred under this situation in 2015, 82 in 2016, 29 in 2017, to 7 in 2018.

To evaluate the possible effect that telemedicine may might had on the patient’s waiting time (WT) for their first Neurology appointment at the Neurology clinic of the HHT, WT data was distributed in 4 frames: up to 6 months, 7 to 10 months, 13 to 24 months, and over 24 months (Table 3). The average WT was 10.5 ± 8.7 months for patients consulting in situ at the HHT and 6.23 ± 6.82 months. Out of the total cohort analyzed in this study, 3845 patients (47%) waited for up to 6 months for their appointment, 944 (11%) waited between 7 and 12 months, 2618 (32%) waited between 13 and 24 months, and 862 (10%) waited for over 24 months, a distribution similar to that observed in the group of patients that consulted their neurologist in situ at the HHT (Table 3). In contrast, patients enrolled in the Teleneurology Program showed a different distribution, with 1053 (60%) waiting for up to 6 months, 228 (13%) waiting between 7 and 12 years, 346 (20%) waiting between 13 and 24 months, and 116 (7%) waiting for over 24 months (Table 3).

Kaplan-Meier survival analyses to better understand the putative effect of the Teleneurology program on patient WT, which resulted in the selection of 3 variables significantly showing an effect on the mean WT: male gender, female gender and patient referral from primary and secondary healthcare facilities (mean and median data summarized in Table 4). As depicted in Fig. 1, Kaplan-Meier function graphs show lower WT for patients who were enrolled in the Teleneurology Program compared to those who consulted their specialist in situ at the HHT. Male patients (panel A in Fig. 1) displayed significant difference in the median WT, with 21.7 ± 0.18 months (95% CI 21.3–22.0) for an in situ appointment, and 16.2 ± 0.60 months (95% CI 15.1–17.4) for an appointment with the telepresence of the specialist. A significant difference (p <  0.05) was also found in the median WT of female patients (panel B in Fig. 1), with 16.9 ± 0.29 months (95% CI 16.3–17.5) for an appointment in situ at HHT, and 7.2 ± 0.45 months (95% CI 6.3–8.1) when enrolled in the Teleneurology Program. The third variable which resulted with a significant median WT difference was the referral from primary or secondary healthcare facilities (panel C in Fig. 1), with 18.3 ± 0.15 months (95% CI 18.6–19.1) for in situ appointments and 4.4 ± 0.29 months (95% CI 3.8–5.0) for telepresence appointments. No differences were found when analyzing data according to any of the age groups or when patients were referred by tertiary healthcare services.

Finally, a backward Cox regression analysis was carried out to understand the effect sizes of the 3 variables identified by the Kaplan-Meier analysis. As shown in Table 5, this analysis resulted in only one variable displaying a significant effect size (p <  0.001) on patient WT: “Type of Appointment”. This variable showed a beta coefficient of 1.91 ± 0.29 fold WT when it took place in situ at the HHT, as compared with patients consulting their neurologist by telepresence. This resulted in an odds ratio of 6.74 in the WT of patients with a traditional in situ appointment, compared to those enrolled in the Teleneurology Program (Table 5).