Transcript Assessment of Neurological Services as a Model of Health

What is happening in
Neurology?
Orla Hardiman MD,FRCPI, FAAN
Director of Neurology
Beaumont Hospital
What is a Neurological
Condition?
• A condition that affects the brain, spine
or muscle
• Can be roughly divided into 3 categories
– Physically disabling
– Non-Physically disabling
– Loss of cognitive ability (Dementia)
In Health Policy, Neurological Disorders
can be Used as a Model for Management
of Chronic Disease
• Acute events with subsequent life long disability
(stroke)
• Treatable conditions that can be “normalised”
(migraine, epilepsy)
• Untreatable conditions that are fatal (motor
neurone disease)
• Untreatable conditions that are progressive and
associated with high burden for patient and
carer (Parkinsons, Alzheimers)
Neurological Disability:
The Brain Matters
• 80% of 10 commonest disabling disease are
neurological
• In Europe, brain diseases cause a loss of 23%
of years of healthy life
• Brain diseases account for 50% of years lived
with disability
• 35% of the total burden of disability-adjusted life
years caused by brain diseases
Prevalence of Neurological
Conditions in Ireland
• Approx 500,000 (12%) suffer from a neurological
disorder
• Stroke is one of the leading causes of death and
disability
• Conditions are frequently undiagnosed : There is poor
access to relevant specialists
• No official data collection has been established for
neurological conditions (except CJD)
• No official management plan or strategy has been put in
place
Neurological Care in Ireland
Equity of Care for People with
Neurological Disability
Studies from Beaumont Hospital
Neurologists in Europe
Distribution of neurologists in Europe
Distribution of neurologists in Europe
8 100
It a ly
It a ly
N o rw a y
18 400
N o rw a y
D e nma rk
D e nma rk
Gre e c e
21 200
21 300
A us t ria
23 200
A us t ria
Lux e mb o urg
23 900
Lux e mb o urg
N e t he rla nd s
25 800
29 100
N e t he rla nd s
S w it z e rla nd
Gre e c e
S w it z e rla nd
P o rt ug a l
33 100
P o rt ug a l
Sweden
35 600
Sweden
38 500
F ra nc e
F ra nc e
177 000
UK
UK
333 300
Ire la nd
0
400000
Population per neurologist
Ire la nd
0
25
50
75
100
Neurologists per million population
125
Community and Outpatient
Services
Out patient Clinics
9 weekly Neurology clinics at Beaumont
3 general
6 specialist
Approximately 50 new patients and 90
return patients seen each week
However….
Summary of Current Status
• 28% of patients with progressive neurological
disability (Multiple Sclerosis or Motor Neurone
Disease) have never or rarely seen a
neurologist…
• Larger percentage of patients with other
neurological conditions are not followed by a
neurologist
• The waiting list for a new patient in a Neurology
clinic is 2 years
• Private clinics have longer waiting lists than
public clinics
Community Services
• The waiting list for community occupational therapy is a
minimum of 9 months except in extreme cases
• Community based Speech and Language Therapy nonexistent for adults
• Services are “means tested”: Require medical card for
access
• Services not available in the private sector
Access to Community Physiotherapy and Occupational
Therapy by patients with Multiple Sclerosis and Motor
Neurone Disease
100%
80%
60%
MS
40%
MND
20%
0%
Physio
OT
In Patient Services
Beaumont Hospital In-Patient
Audit
Admissions to Beaumont Neurology corrected for Regional
Population
40
30
20
10
Health Board
SE
H
B
B
SH
B
W
H
N
EH
B
N
B
W
H
M
B
H
M
B
W
H
HA
0
ER
Patients per 100,000
population
Admissions by health board region
(Corrected for regional population)
M
ns
on
D
s
n
de
r
le
m
s
is
or
Pr
ob
ND
CI
DP
M
St
ro
ke
Sc
le
ro
si
s
ile
ps
y
Ep
Di
se
as
e
M
M
en
ya
ei
st
gi
he
ts
ni
a
G
ra
vi
s
Pa
rk
i
ve
rs
io
ac
k
le
ul
t ip
ca
lB
Co
n
ed
i
M
In Patient Admissions to Neurology at Beaumont
Hospital 2003 (n=650)
140
120
100
80
Admissions
60
40
20
0
Waiting Lists for Admission
Geographic Inequity
Patients on waiting list compared
with admissions
% Elective
admissions
% Patients
on Waiting
Lists
ERHA
55%
34%
Other HBs
45%
66%
WAITING TIMES FOR PATIENTS WHO
WERE ADMITTED
No of
Patients
<1
Months
>1 but <3 >3 but <
>6
Months
6 Months Months
Percentage of
patients who
waited greater
than 6
months
ERHA
WHB
MHB
MWHB
NEHB
NWHB
SHB
SEHB
83
14
6
5
21
10
12
16
14
0
1
2
13
6
2
1
9.7%
5.8%
11%
0%
6.4%
12%
0%
18%
14
2
1
0
4
6
0
1
12
1
1
0
3
3
0
4
Top five “elective” admissions
Diagnosis
Total
Duration
number of
of stay
Admissions
Mean
duration of
stay
Epilepsy
60
1- 62 days 12 days
MS
53
1-91 days
12 days
MND
29
5- 34
days
13 days
Stroke
19
1 – 78
days
15 days
Chronic
inflammatory
18
4- 40
days
8 days
Patients Waiting for Admission for
longer than 6 Months
Percentage of patients from each Health Board Region
w ho have w aited for More than 6 Months (n=89)
B
W
H
HB
M
NE
HB
HB
NW
B
SE
H
SH
B
HB
M
ER
HA
90
80
70
60
50
40
30
20
10
0
Multidisciplinary Clinics
Beneficial Effects of
Multidisciplinary Management
Multidisciplinary Teams
• Hospital based
–
–
–
–
–
–
–
–
–
Neurologist
Specialist nurse
Physiotherapist
Occupational therapist
Speech & language
Nutritionist
Psychologist
Social worker
Palliative care team
• Community based
–
–
–
–
–
–
–
–
Specialist nurse
Voluntary organisation
Public health nurse
Occupational therapist
Physiotherapist
Speech and Language
Social Services
Palliative care home
team
Effect of a Multidisciplinary Clinic on
Survival in Motor Neurone Disease
1
.8
Cum. Survival (general)
n = 258 pts.
.6
.4
Cum. Survival (multidisciplinary) n = 108 pts.
.2
Logrank p = 0.003
0
0
.5
1
1.5
2
2.5
3
3.5
4
4.5
Time from diagnosis (years)
Multidisciplinary Clinics: Evidence
from other Countries
•
•
•
•
•
•
Better survival
Fewer emergency admissions
Shorter length of stay when hospitalised
Better management of symptoms
Improved quality of life
Lower rates of carer burnout
Why has there been no
Investment in Neurology?
Reactive versus Proactive Health
Policy
Waiting Lists
Excessive reliance on unverified / inaccurate data,
including waiting list data
• Minimal audit of waiting list management:
– Equity not assessed or validated
• Assumption that “outcome” is associated with
“procedure” (usually surgical)
What Needs to be Done
• We need to develop more sophisticated
measurement tools that can capture
complex conditions
• We need to develop methods to capture
out-patient services and activities
• We need to audit and monitor our activity
to ensure that we are capturing real need
What Needs to be Done (cont’d)
• We need to be sensitive to hidden
inequities within the health services
• We need measurement tools that assess
continuity of care
What Needs to Be Done?
• We need to invest in the delivery of
Neurological Services