what is happening in neurology?
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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 - PowerPoint PPT PresentationTRANSCRIPT
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What is happening in Neurology?
Orla Hardiman MD,FRCPI, FAAN
Director of Neurology
Beaumont Hospital
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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)
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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)
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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
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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
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Neurological Care in Ireland
Equity of Care for People with Neurological Disability
Studies from Beaumont Hospital
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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
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Community and Outpatient Services
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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….
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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
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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
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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
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In Patient Services
Beaumont Hospital In-Patient Audit
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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
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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
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Waiting Lists for Admission
Geographic Inequity
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Patients on waiting list compared with admissions
% Elective admissions
% Patients on Waiting
Lists
ERHA 55% 34%
Other HBs 45% 66%
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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%
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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
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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
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Multidisciplinary Clinics
Beneficial Effects of Multidisciplinary Management
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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
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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
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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
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Why has there been no Investment in Neurology?
Reactive versus Proactive Health Policy
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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)
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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
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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
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What Needs to Be Done?
• We need to invest in the delivery of Neurological Services