ObjectiveTo assess the implementation of teleneurology (TN), including patient and clinician experiences, during the coronavirus respiratory disease 2019 (COVID19) pandemic.MethodsWe studied synchronous (video visit) and asynchronous (store-and-forward, patient-portal evaluation, remote monitoring) TN utilization in the Mount Sinai Health System Neurology Department in New York, 2 months before and after the start of our department's response to the pandemic in mid-March 2020. Weekly division meetings enabled ongoing assessments and analysis of barriers and facilitators according to the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change models. We used post-visit surveys of clinicians (from April 13 to May 15, 2020) and patients (from May 11 to 15, 2020) to determine technology platforms used, and TN experience and acceptability, using Likert scales (1 = very poor/unlikely to 5 = very good/likely).ResultsOver the 4-month period, 117 TN clinicians (n = 14 subspecialties) conducted 4,225 TN visits with 3,717 patients (52 pre-vs 4,173 post-COVID19). No asynchronous TN services were delivered. Post-COVID19, the number of TN clinicians, subspecialties performing TN, and visits increased by 963%, 133%, and 7,925%, respectively. Mean acceptability among patients and clinicians was 4.7 (SD 0.6) and 3.4 (SD 1.6), respectively. Most video visits were completed using Epic MyChart (78.5%), and Zoom (8.1%). TN implementation facilitators included Medicare geographic restriction waivers, development of clinician educational materials, and MyChart outreach programs for patients experiencing technical difficulties.ConclusionsA significant expansion of TN utilization accompanied the COVID19 response. Patients found TN more acceptable than did clinicians. Proactive application of an implementation framework facilitated rapid and effective TN expansion.

IntroductionThe need for quantitative criteria to appraise the quality of implementation research has recently been highlighted to improve methodological rigour. The Implementation Science Research development (ImpRes) tool and supplementary guide provide methodological guidance and recommendations on how to design high-quality implementation research. This protocol reports on the development of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool, a quantitative appraisal tool, developed based on the structure and content of the ImpRes tool and supplementary guide, to evaluate the conceptual and methodological quality of implementation research.Methods and analysisThis study employs a three-stage sequential mixed-methods design. During stage 1, the research team will map core domains of the ImpRes tool, guidance and recommendations contained in the supplementary guide and within the literature, to ImpResPAC. In stage 2, an international multidisciplinary expert group, recruited through purposive sampling, will inform the refinement of ImpResPAC, including content, scoring system and user instructions. In stage 3, an extensive psychometric evaluation of ImpResPAC, that was created in stage 1 and refined in stage 2, will be conducted. The scaling assumptions (inter-item and item-total correlations), reliability (internal consistency, inter-rater) and validity (construct and convergent validity) will be investigated by applying ImpResPAC to 50 protocols published inImplementation Science. We envisage developing ImpResPAC in this way will provide implementation research stakeholders, primarily grant reviewers and educators, a comprehensive, transparent and fair appraisal of the conceptual and methodological quality of implementation research, increasing the likelihood of funding research that will generate knowledge and contribute to the advancement of the field.Ethics and disseminationThis study will involve human participants. This study has been registered and minimal risk ethical clearance granted by The Research Ethics Office, King’s College London (reference number MRA-20/21-20807). Participants will receive written information on the study via email and will provide e-consent if they wish to participate. We will use traditional academic modalities of dissemination (eg, conferences and publications).

BackgroundPatient groups traditionally affected by health disparities were less likely to use video teleneurology (TN) care during the initial COVID-19 pandemic surge in the United States. Whether this asymmetry persisted later in the pandemic or was accompanied with a loss of access to care remains unknown.MethodsWe conducted a retrospective cohort study using patient data from a multicenter healthcare system in New York City. We identified all established pediatric or adult neurology patients with at least two prior outpatient visits between June 16th, 2019 and March 15th, 2020 using our electronic medical record. For this established pre-COVID cohort, we identified telephone, in-person, video TN or emergency department visits and hospital admissions for any cause between March 16th and December 15th, 2020 (“COVID period”). We determined clinical, sociodemographic, income, and visit characteristics. Our primary outcome was video TN utilization, and our main secondary outcome was loss to follow-up during the COVID period. We used multivariable logistic regression to model the relationship between patient-level characteristics and both outcomes.ResultsWe identified 23,714 unique visits during the COVID period, which corresponded to 14,170 established patients from our institutional Neurology clinics during the pre-COVID period. In our cohort, 4,944 (34.9%) utilized TN and 4,997 (35.3%) were entirely lost to follow-up during the COVID period. In the adjusted regression analysis, Black or African-American race [adjusted odds ratio (aOR) 0.60, 97.5%CI 0.52–0.70], non-English preferred language (aOR 0.49, 97.5%CI 0.39–0.61), Medicaid insurance (aOR 0.50, 97.5%CI 0.44–0.57), and Medicare insurance (aOR 0.73, 97.5%CI 0.65–0.83) had decreased odds of TN utilization. Older age (aOR 0.98, 97.5%CI 0.98–0.99), female sex (aOR 0.90 97.5%CI 0.83–0.99), and Medicaid insurance (aOR 0.78, 0.68–0.90) were associated with decreased odds of loss to follow-up.ConclusionIn the first 9 months of the COVID-19 pandemic, we found sociodemographic patterns in TN utilization that were similar to those found very early in the pandemic. However, these sociodemographic characteristics were not associated with loss to follow-up, suggesting that lack of TN utilization may not have coincided with loss of access to care.

BACKGROUND Mobile applications, or “apps”, are widely used by people with epilepsy, their caregivers, and providers. The impact of these apps on the clinical effectiveness (CE) and feasibility, acceptability, or usability (FAU) in epilepsy remains unclear. OBJECTIVE To conduct a systematic review of studies investigating the CE and FAU of mobile applications in epilepsy. METHODS This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards and was registered with the Prospective Register of Systematic Reviews (PROSPERO; CRD42019134848). The search was conducted using MEDLINE ALL (Ovid) and EMBASE (Ovid) from database inception to April 2022. At the screening phase, we excluded conference abstracts, non-English language and review articles, as well as articles studying video telehealth. We determined study quality for case-control or cohort studies using the Newcastle-Ottawa Quality Assessment Scale (NOQAS) and bias in randomized studies using the Cochrane Collaboration Handbook Risk of Bias (RoB) tool. We assessed usability study quality using the validated 15-point Silva scale. Study characteristics were analyzed using summary statistics. RESULTS We identified 6,768 studies, of which 13 (0.2%) were included. Of the 13 studies, 8 (61.5%) addressed CE, 6 (46.2%) acceptability, 5 (38.5%) usability, and 4 (30.8%) feasibility. Four studies (31.0%) evaluated both CE and FAU. Studies comprised prospective cohort (N=6, 46.2%), pilot (N=3, 23.1%), randomized trial (N=3, 23.1%) and pre/post (N=1, 7.7%) designs. Overall, cohort studies demonstrated fair quality (median NOQAS score 5, interquartile range [IQR] 5.0 - 5.8), whereas 2 (66.7%) randomized studies had some concern for bias. Usability studies demonstrated high methodological quality (median Silva score 10, IQR 10 - 11). Apps were most frequently studied in patient users (N=7 (87.5%) CE and 8 (100%) FAU studies). The most common app target in CE studies was physical health (N=5, 62.5%) contrasting with symptom management (N=7, 87.5%) in FAU studies. CONCLUSIONS We found that studies of app use in epilepsy most commonly studied CE and evaluated patient-facing apps. Despite high methodological quality in usability studies and several randomized CE studies, cohort and randomized studies demonstrated fair quality and moderate bias, respectively. Additional high-quality evidence is necessary to evaluate the CE and FAU of app use in epilepsy.

Objective To identify the characteristics associated with high utilization of remote communications (RCs) in patients with headache. Background Patients with headache frequently communicate with their providers using secure portal messaging and telephone calls. However, clinical and demographic factors as well as visit patterns associated with RC utilization remain poorly characterized. Methods We retrospectively analyzed data from patients with headache who were evaluated in the ambulatory neurology faculty practice at the Icahn School of Medicine at Mount Sinai in New York between January 1 and June 30, 2019. We extracted clinical and demographic characteristics, total office visits, secure MyChart portal messages, and telephone encounters from our institutional data warehouse. We defined high RC and MyChart utilization as the top tertile of RC and MyChart message volume, respectively, and assessed the relationship between patient characteristics and high RC (primary outcome), as well as high MyChart utilization (secondary outcome). We characterized the relationship between clinicodemographic characteristics and the ratio of MyChart messages to total RCs (secondary outcome). Results We identified 1390 patients, of whom 477 (34.3%) were high RC utilizers and 321 (23.1%) were high MyChart utilizers. High RC utilizers generated 3306/3921 (84.3%) RCs. The presence of chronic headache (aOR 2.31, 95% CI 1.75–3.03, p < 0.0001), cluster headache (aOR 18.3, 95% CI 5.0–71.7, p = 0.001), and migraine (aOR 3.82, 95% CI 1.93–9.3, p = 0.011) was associated with high RC utilization. Patients ≥65 years of age were less likely to engage in MyChart messaging as a proportion of RC (191/680, 28.1%) compared with patients 18–30 years of age (243/620, 39.2%, p = 0.049) and 30–64 years of age (1172/2721, 43.1%, p < 0.0001). Conclusions A minority of patients with headache (477/1390; 34.3%) generated the majority (3306/3921; 84.3%) of RCs. Our findings should be validated in external patient cohorts with the objective of developing strategies to optimize RC utilization.