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325 Assessing the impact of blended outreach and telemedicine paediatric neurology specialist services in Myanmar

Background Myanmar has an improving health picture with significant reductions in neonatal and paediatric mortality. However, there remain significant regional variations in specialist expertise and care. Regarding the paediatric neurology services, there are only 11 paediatric neurologists for a paediatric population of about 14 million children (26% of the total population). Children in Myanmar’s rural communities, 70% of the total population, live in conditions which both drive the neurological burden and limit access to effective treatment. Recognising the burden and barriers to specialist services, we present evidence from an expanding programme of blended outreach and telemedicine with the overall aim of increasing the number of children in remote areas who gain access to specialist neurological assessment and treatment. Objectives This study aimed to assess the scope and impact of those outreach and telemedicine paediatric neurology specialist services. Methods The outreach clinics were of a two-stream model with face-to-face consultations by up to three paediatric neurologists from Yangon. This service was supplemented using telemedicine clinics and mobile instant messaging applications for follow up and any emergency problems between individual outreach clinics. Whilst most children were seen on an outpatient basis, the visiting specialist also saw admitted children with neurological problems during outreach clinic visits providing an expert opinion. Continued medical education activities were also conducted for local doctors and nurses. Data including patient numbers, different neurological conditions, cost-effectiveness, and patient satisfaction responses were analysed. Results We started visits to regional hospitals in 2017 and 2018 before upscaling in 2019, to provide quarterly visits to 7 regional and district hospitals who had previously had no access to any paediatric neurology service provision aside from tertiary referral. Altogether, 1327 children with different neurological problems were seen in 2019. This included 712 children (54%) with epilepsy, 155 children (12%) with cerebral palsy and 100 children (8%) with other developmental problems. The costs of facilitating the clinics were compared to the equivalent cost of the patients travelling to a tertiary centre for the same level of specialist assessment and treatment. Percentage of cost-saving was from 81% to 98% depending on the distance between the regional hospital and Yangon where the tertiary centre is located. We conducted a small survey of parents attending the clinic. Respondents felt that the outreach clinics provided a more accessible point of care. Many highlighted the lifting of a significant financial burden, particularly in low-income households. The reduction of financial cost is felt particularly in cases such as epilepsy which require multiple clinic visits and ongoing specialist care. Many comments have also identified the quality of specialist care in the new model, comparable to a tertiary hospital. Conclusions Paediatric neurology outreach and virtual clinics can provide a model for other specialities across many fields of healthcare, especially in countries with good internet, but poor transport. Interval telemedicine services also provided a continuation of care. To achieve specialist care at greater scale new approaches, such as the blended outreach and telemedicine structure described here, should be actively developed and evaluated.