Patient Travel Distance to Neurologist Visits

Abstract

Background and Objectives: The density of neurologists within a given geographic region varies greatly across the US. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. Methods: We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least one outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles one-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region (HRR) and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. Results: We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of these, 96,213 (17%) traveled long-distance for care. Median driving distance and time were 81.3 (IQR:59.9-144.2) miles and 90 (IQR:69-149) minutes for patients with long-distance travel compared to 13.2 (IQR:6.5-23) miles and 22 (IQR:14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), ALS(32.1%) and MS(22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (1st quintile: OR 3.04[95%CI:2.41-3.83]vs. 5th quintile), rural setting (4.89[4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41[3.14-3.69] and 5.27[4.72-5.89], respectively). Nearly one third of patients bypassed the nearest neurologist by 20+ miles and 7.3% of patients crossed state lines for neurologist care Conclusions: We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles one-way for care and travel burden was most common for lower prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurological subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Teleneurology and Artificial Intelligence in Clinical Practice

“…22 Approximately 20% of Medicare beneficiaries live 50 miles or more from their neurologist, and those living 50 miles or more were 26% less likely to follow up compared with those who lived closer than 50 miles. 22 Telehealth does improve access to care for some 23 ; however, with the expansion of these services, existing disparities may not be improved and are sometimes exacerbated, creating a worsening digital divide. Studies looking at the adoption of teleneurology during the COVID-19 pandemic showed that older men of color and those with Medicare or Medicaid were less likely to complete video visits compared with younger White women with private insurance.…”

“…One of the advantages of telehealth is thought to be improved access by reducing the need for patients to travel. Although 20% of the US population resides in rural areas, only 9% of physicians and 10% of specialists practice in these areas 22 . Approximately 20% of Medicare beneficiaries live 50 miles or more from their neurologist, and those living 50 miles or more were 26% less likely to follow up compared with those who lived closer than 50 miles 22 .…”

“…Although 20% of the US population resides in rural areas, only 9% of physicians and 10% of specialists practice in these areas 22 . Approximately 20% of Medicare beneficiaries live 50 miles or more from their neurologist, and those living 50 miles or more were 26% less likely to follow up compared with those who lived closer than 50 miles 22 . Telehealth does improve access to care for some 23 ; however, with the expansion of these services, existing disparities may not be improved and are sometimes exacerbated, creating a worsening digital divide.…”

The Diagnostic Landscape of Adult Neurogenetic Disorders

“…Even with the advent of new genetic diagnostic tools, most patients have limited access to neurological care [132,133] and/or medical genetics services [2,134,135], and concentrated expertise in rare diseases limits the scope of expedient and accurate diagnosis of adult patients with neurogenetic diseases. Collaboration between neurologists and geneticists is needed to better incorporate clinical and genetic data.…”

Author Response: Patient Travel Distance to Neurologist Visits

“…Our finding that Black patients travel shorter distances does not mean that Black patients have better access to neurologic care compared with White patients. 1 Transportation insecurity is one potential reason that travel distance might have been shorter for Black patients. Furthermore, we focused on travel distance, but other measures of access such as seeing an outpatient neurologist and referrals to subspecialists care were not studied and are also important.…”