Neurological Teleconsultations in General Practice: A Stepped-Wedge Cluster Randomized Clinical Trial.

Abstract

Incorporating teleneurology into primary care aimed to improve access to neurological care in a rural region in Germany. A telemedicine network connecting neurologists, general practitioners (GPs), and patients was established. To determine whether teleneurology services in rural primary care increased the proportion of patients with neurological symptoms managed solely in general practice. The NeTKoH study (Neurological Teleconsultation With General Practitioners to Strengthen Specialist Care in Western Pomerania, Germany) was a stepped-wedge cluster randomized clinical trial conducted from January 1, 2021, through July 31, 2025, to compare teleconsultations vs standard care. Patients were continuously approached and eligible if they were aged 18 years or older and presented at one of 41 participating GP practices in northeast Germany with symptoms for which a neurological consultation was deemed necessary. The duration of patient follow-up was 3 months. Data analysis was conducted from January to July 2025. Practices were equipped with a telemedicine system to enable a video conference between the GP and patient on 1 side and a neurologist on the other side to obtain immediate neurological assessment and guide further care decisions. The primary outcome was the proportion of patients who continued to be managed solely within general practice. Between October 15, 2021, and October 25, 2024, 986 patients were enrolled (intervention: 517 patients; control: 469 patients); 3 of these patients were excluded, leaving 983 patients for analysis (605 [61.5%] female; median [range] age, 55 [18-90] years). Teleconsultations, compared with standard care, resulted in fewer patients managed solely within general practice (38.3% vs 50.7%; adjusted odds ratio, 0.58; 95% CI, 0.38-0.88). Referrals to neurologists decreased with teleconsultations compared with standard care (36.4% vs 41.4%), while referrals to other specialists (11.9% vs 4.7%) and hospitals (12.8% vs 2.6%) increased. No significant differences were observed in quality of life or health status. Adherence to recommendations was lower in the intervention phase. At follow-up, more than half of the patients in either group were still managed solely in general practice. This stepped-wedge cluster randomized clinical trial suggests that neurological teleconsultations in general practice may have helped triage patients (eg, to other specialists or hospitals) and therefore contributed to improved medical care, particularly in structurally underserved areas; however, an immediate reduction in the use of secondary care was not found. The inability to blind GPs to the randomization may have introduced selection effects, which should be considered in future studies. German Clinical Trials Register Identifier: DRKS00024492.