Can You Hear Me Now? Telephone-Based Teleneuropsychology Improves Utilization Rates in Underserved Populations

Abstract

Limited access to health care is a barrier that may result in delayed diagnoses and treatment (Agency for Healthcare Research and Quality [AHRQ], 2019), contributing to adverse outcomes (Clarke, Weuve, Barnes, Evans, & Mendes de Leon, 2015; Carvalho et al., 2015) and thus, higher health care costs (LaVeist, Gaskin, & Richard, 2011). Historically, those affected by lack of health care access are from culturally diverse backgrounds (AHRQ, 2019). Access is further compounded by health literacy (Cutilli & Bennett, 2009), distrust associated with information/data collection, as well as concerns of privacy protection (Page, Venkataramani, Beyrer, & Polk, 2020), and higher frequency of missed appointments in those with lower socioeconomic status (Barron, 1980; Sharp & Hamilton, 2001; Ellis, McQueenie, McConnachie, Wilson, & Williamson, 2017) and/or lack of transportation options (Farley, Wade, & Birchmore, 2003; Neilsen, Faergeman, Foldspang, & Larsen, 2008; Parkland Health & Hospital System [PHHS] & Dallas County Health and Human Services [DCHHS], 2019). The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic highlights the continued disparity of adverse health outcomes previously seen in other disease states (Washington, 2006). In fact, recent data show that COVID-19-associated hospitalization rates are roughly four times higher in the Black population and three times higher in the Hispanic/Latinx cohort when compared with Whites (Centers for Disease Control and Prevention [CDC], 2020). The pandemic also required a rapid shift in telemedicine delivery to minimize face-to-face interaction and to quell spread. Telemedicine already occurs across several disciplines, including primary care (Powell, Hestenburg, Cooper, Hollander, & Rising, 2017), radiology (Halvorsen & Kristiansen, 1996), neurology (Davis, Coleman, Hanar, & King, 2014), behavioral health (Mochari-Greenberger, Vue, Luka, Peters, & Pande, 2016), psychiatry (Fortney et al., 2015), and neuropsychology (Brearly et al., 2017). Historically, these services were geared toward providing specialty care to rural and underserved populations (Grubaugh, Cain, Elhai, Patrick, & Frueh, 2008; Harrell, Wilkins, Connor, & Chodosh, 2014). Therefore, telemedicine neuropsychological services have the potential to increase access to services and decrease no-show rates compared with in-person evaluation by reducing barriers related to accessibility, including the burden of transportation. Telehealth-based neuropsychology (TeleNP) research supports the feasibility of videoconferencing delivery (Cullum, Hynan, Grosch, Parikh, & Weiner, 2014) with good reliability (Brearly et al., 2017) and validity (Marra, Hamlet, Bauer, & Bowers, 2020; Wadsworth et al., 2018). However, previous telehealth research with culturally diverse populations highlights apprehensiveness with telemedicine (George, Hamilton, & Baker, 2012), including feeling self-conscious while on camera (Nittari et al., 2020), raising the question of if audio-only services would be preferred. Furthermore, although initial recommendations for videoconferencing-based TeleNP services are previously outlined (Grosch, Gottlieb, & Cullum, 2011), they lack sufficient empirical support for direct to home audio-only service delivery. Before the advent of videoconference-based telehealth, telephones were used effectively to conduct clinical interviews and assess for psychiatric and cognitive conditions (e.g., Aziz & Kenford, 2004; Brandt, Spencer, & Folstein, 1988; Simon, Fleiss, Fisher, & Gurland, 1974; Wilson, Wilfley, Agras, & Bryson, 2010). Since the 1980s, telephone administration included cognitive screening and assessments with results similar to face-to-face testing (e.g., Brandt et al., 1988; Castanho et al., 2016; Plassman, Newman, Welsh, & Helms, 1994). Many of the measures available for telephone delivery are easily accessible and culturally adapted (e.g., Järvenpää et al., 2002). Thus, TeleNP delivery may be particularly well suited to enhancing access to services across populations. However, recent systematic reviews and meta-analyses of teleconferencing neuropsychological assessment (Brearly et al., 2017; Carlew et al., in press; Marra et al., 2020) highlight the lack of linguistic and cultural guidelines for interpreter-mediated neuropsychological video or telephone-based evaluations. Furthermore, the Inter Organizational Practice Committee Guidelines (Bilder et al., 2020a) and other sources (e.g., Kruse et al., 2018), consistent with the American Psychological Association’s [APA] multicultural guidelines (2017b), encourage special consideration of linguistically and culturally diverse groups. Certainly, the APA Ethics Code Principle of Justice highlights the importance of thoughtfully promoting equal access to services, within one’s bounds of competence, across populations (APA, 2017a). Given the staggering disproportion of minorities affected by COVID-19 (CDC, 2020) and apprehension among diverse populations with video-based delivery (George et al., 2012; Nittari et al., 2020), a continued focus on how TeleNP could be utilized to make cognitive assessment more accessible is warranted. The purpose of this paper is to examine clinical utilization of neuropsychological services between in-person versus TeleNP in underserved populations. It was hypothesized that TeleNP would improve show rates for county hospital patients, given the mitigating nature of the modality on barriers to care. Data were obtained from an Institutional Review Board-approved deidentified database within a community hospital outpatient neuropsychology clinic (N = 322) and are representative of a focus group conducted with residents of Dallas county (N = 820; PHHS & DCHHS, 2019), thus increasing potential generalizability of findings from the current study. Roughly 28% of the clinic sample are monolingual Spanish, 5% are bilingual (Spanish/English), and the remaining 67% are monolingual English. Linguistic background is assessed during the clinical interview using open and closed ended questions (e.g., linguistic preference for consuming media, speaking with family/friends, school/work tasks) to inform degree of bilingualism and preference for conducting the evaluation in English or Spanish. A total of 174 patients were scheduled for neuropsychological services at a community hospital in Dallas County from November 2019 to June 2020. Starting March 18, 2020, all patients were seen via TeleNP. In order to compare clinical utilization rates of in-person versus TeleNP, data for in-person services were retrospectively analyzed from the 4-month time frame prior to COVID-19 (November 2019 to first half of March 2020) and compared with TeleNP services provided between March 18, 2020 and June 2020. Regardless of service delivery modality, the evaluation consisted of record review, clinical interview, neuropsychological testing, and interactive feedback on the same day. The start times of the clinical evaluations remained consistent (8 a.m. or 9 a.m.), but the time blocks were changed from 4 hr for in-person evaluations to 2 hr for TeleNP evaluations. The patients were called by the psychometrist prior to appointments to confirm the appointment and to reiterate the anticipated length of the evaluation. Patient clinical utilization was classified into three groups: completed appointment, no-show, and canceled (e.g., rescheduled prior to original appointment). Demographic information for patients who completed their appointment was obtained through self-report. For those who were not seen, demographic information was obtained through a chart review. A total of 90 patients were scheduled for in-person neuropsychological evaluations between November 2019 and February 2020. A total of 84 patients were scheduled via TeleNP from March to June 2020 during the COVID-19 pandemic. The overall sample had a mean age of 53.06 (standard deviation [SD] = 16.24) and mean education of 10.9 (SD = 3.76). Those who self-identified as having Hispanic/Latinx origins made up the largest ethnicity group at (39.1%), followed by Black (35.1%), White (24.7%), and Native American (1.1%; See Table 1 for full results). There were no differences between visit types (i.e., in-person vs. TeleNP) in age, F(1, 173) = 0.518, p = .473, or education, F(1, 116) = 0.613, p = .435. When examining differences by race/ethnicity, there was no significant difference in age, F(3, 170) = 0.349, p = .790. However, there were significant differences in years of education, F(3, 113) = 10.762, p < .001, with Hispanic/Latinx patients having fewer mean years of education (M = 8.99, SD = 4.27) than Black (M = 12.08, SD = 2.30), White (M = 12.67, SD = 2.29), and Native American patients (M = 15.50, SD = 6.36). Given the small number of Native American patients, follow-up analysis of variance and chi-square analyses excluding Native American patients were run, and findings for age/education by ethnicity were not altered. Demographic and utilization data comparing in-person and TeleNP service delivery (N = 174) Demographic and utilization data comparing in-person and TeleNP service delivery (N = 174) When comparing show rates, these improved by 24% (55.6% vs. 79.8%) when services were rendered via TeleNP versus in-person. Overall, there was an increase in completed visits and a decrease in no-show and cancelations irrespective of race/ethnicity. See Table 1 for a breakdown of clinic utilization by race/ethnicity. To elucidate the difference in total evaluation time (e.g., record review, clinical interview, testing by technician and/or psychologist, integration/report generation, and interactive feedback), a random sampling of 20 patients were selected (10 in-person and 10 TeleNP) and total evaluation time was calculated. For in-person evaluations, the mean number of minutes per evaluation was 574, with a range of 493 min–670 min. For TeleNP, the mean was 166 min with range of 115 min–206 min. Testing/scoring time as well as total professional time were the largest discrepancy, with in-person averaging 277.5/262.3 min compared with TeleNP’s 41/94.2 min for testing/scoring and professional time, respectively. In sum, in-person evaluations averaged 9.57 hr and TeleNP evaluations averaged 2.76 hr. Using local Center for Medicaid and Medicaid Services billing, the reduction in time correlates with a $500 savings in health care costs per evaluation. Access to health care, including underutilization of neuropsychological services (Rivera Mindt, Byrd, Saez, & Manly, 2010), continues to be a barrier to those underserved, particularly among those of underrepresented racial/ethnic backgrounds (National Academies of Sciences, Engineering, and Medicine, 2017). This important social determinant of health was of primary concern in a community survey for patients in the current study (Hill, Pérez-Stable, Anderson, & Bernard, 2015; PHHS & DCHHS, 2019). As Suarez, Casas, Lechuga, & Cagigas (2016) noted, inequity is driven by socially, politically, and historically determined starting lines for people. Although systematic differences were found between race/ethnicity groups and education, this did not carry over to show rate data, indicating the potential for TeleNP service delivery to mitigate potential effects when individuals have less access to formal education. This inequality in starting lines has again been amplified in the midst of this pandemic, with disproportional rates of COVID-19 infections, related hospitalizations, and deaths (CDC, 2020; Garcia, Homan, García, & Brown, 2020). Notably, in the present study, offering services via TeleNP increased show rates by 24% across all races/ethnicities, highlighting that type of service delivery could be a contributing factor related to equitable accessibility of health care. In addition to increasing show rates, the current study highlights that the onus is on health providers to adapt service delivery and reduce economic costs of services for patients, consistent with APA Ethical Principal of Justice (APA, 2017a). The focused data pull (n = 10 for each modality) demonstrated that TeleNP results in an average of 6.81 hr and approximately $500 saved per evaluation. At first blush, spending nearly seven less hours per evaluation is quite a stark difference. Although TeleNP is unarguably less comprehensive and necessitates nearly 4 hr less of administration/scoring time, patient satisfaction data demonstrate that quality service may not always require this extra time (Lacritz et al., in press). Further, given the culturally diverse sample, the psychometric data were always interpreted in partnership with rich qualitative information, in accordance with the core tenants of socially responsible neuropsychology (Diaz-Santos et al., 2019). Our data suggest that TeleNP can minimize access disparity and improve access across diverse populations. Post-COVID-19, neuropsychologists could consider offering assessment via multiple modalities, including TeleNP in hybrid assessment options, and advocate for continued reimbursement for these modalities to promote equal access to care (Bilder et al., 2020b). Even in nonpandemic scenarios, TeleNP is appropriate for certain referral questions (Castanho et al., 2014; Kwan & Lai, 2013) and has the potential to save patients time and expense, reduce transportation-related stress, and increase the number of patients able to be evaluated (Bilder et al., 2020b). Our report also has limitations. Our sample of Hispanic/Latinx patients is composed of a diverse group of U.S.-born and foreign-born individuals. Populations with Hispanic/Latinx origins are part of a heterogeneous group in terms of skin color, ancestry, language, and cultural backgrounds. Further, social/political barriers arise and are compounded when limited English proficiency, in part due to reduced access to/quality of education, reduces the opportunities to gain U.S. citizenship, and being afforded with more opportunities for gainful employment and health insurance (Garcia, Garcia, Chiu, Raji, & Markides, 2018; Goel et al., 2003; Laidley, Domingue, Sinsub, Harris, & Conley, 2019). Although TeleNP has potential to lower overall health care costs, it is unclear if this results in reduction of cost to patients, a potentially important variable to consider in trying to increase access. Additionally, despite attempts to continue delivering services to patients during COVID-19 and the benefits outlined in this paper, limitations to TeleNP services exist. TeleNP may not be appropriate in cases of higher levels of cognitive impairment, shorter attention spans, more significant sensory limitations (e.g., hearing), or certain presurgical evaluations. Although the current results show promise for increasing utilization of neuropsychological services in diverse populations by utilizing TeleNP, further research with larger sample sizes is needed to extend these results. Integration of dedicated discussion and/or utilization of questionnaires focused on barriers to care may elucidate areas that can be remediated. Future research is also needed to further validate the efficacy of TeleNP, including considering offering both in-person and TeleNP services postpandemic and TeleNP versus audio–visual telemedicine to examine if there is a difference in patient preference. Future studies should consider if reduction in health care costs via shorter evaluations relates to a reduction in cost to patient. Additional studies should also consider inserectionality of what sociopolitical factors compounded acess (Garcia et al., 2018; Goel et al., 2003; Laidley et al., 2019). In conclusion, this is the first known project to examine if the conversion to TeleNP services resulted in reduced no show or cancelation rates of neuropsychological services in a community hospital. Additionally, TeleNP resulted in shorter batteries and direct cost savings to patients. It appears that TeleNP is poised to provide more affordable services to diverse samples without compromising quality of care. None declared.

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