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

Distribution of neurologists in Europe

8 100

18 400

21 200

21 300

23 200

23 900

29 100

33 100

35 600

38 500

177 000

333 300

25 800

0 400000

Ireland

UK

France

Sweden

Portugal

Switzerland

Netherlands

Luxembourg

Austria

Greece

Denmark

Norway

Italy

Population per neurologist

Distribution of neurologists in Europe

0 25 50 75 100 125

Ireland

UK

France

Sweden

Portugal

Switzerland

Netherlands

Luxembourg

Austria

Greece

Denmark

Norway

Italy

Neurologists per million population

Neurologists in Europe

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 non-existent 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

0%

20%

40%

60%

80%

100%

Physio OT

MS

MND

In Patient Services

Beaumont Hospital In-Patient Audit

Admissions to Beaumont Neurology corrected for Regional Population

Admissions by health board region (Corrected for regional population)

0

10

20

30

40

ERHAW

HBM

HB

MW

HB

NEHB

NWHB

SHB

SEHB

Health Board

Pa

tie

nts

pe

r 1

00

,00

0

po

pu

lati

on

In Patient Admissions to Neurology at Beaumont Hospital 2003 (n=650)

0

20

40

60

80

100

120

140

Epilepsy

Multi

ple S

clero

sis

Stroke

MND

CIDP

Med

ical

Bac

k Pro

blem

s

Conversi

on Diso

rder

Parki

nsons

Disea

se

Men

eigits

Mya

sthen

ia G

ravi

s

Admissions

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 Months

>3 but < 6 Months

> 6 Months

Percentage of patients who waited greater than 6 months

ERHA 83 14 14 12 9.7%

WHB 14 0 2 1 5.8%

MHB 6 1 1 1 11%

MWHB 5 2 0 0 0%

NEHB 21 13 4 3 6.4%

NWHB 10 6 6 3 12%

SHB 12 2 0 0 0%

SEHB 16 1 1 4 18%

Top five “elective” admissions

Diagnosis Total number of

Admissions

Duration of stay

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

neuropathy

18 4- 40

days

8 days

Patients Waiting for Admission for longer than 6 Months

Percentage of patients from each Health Board Region who have waited for More than 6 Months (n=89)

0102030405060708090

ERHAM

HBSHB

SEHB

NWHB

NEHBM

HBW

HB

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

0

.2

.4

.6

.8

1

0 .5 1 1.5 2 2.5 3 3.5 4 4.5Time from diagnosis (years)

Cum. Survival (multi-disciplinary) n = 108 pts.

Cum. Survival (general)n = 258 pts.

Logrank p = 0.003

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