Our study demonstrated that patients found their TN experience highly acceptable regardless of their neurologic condition and that the ICD10 diagnosis category was not significantly associated with the acceptability of TN care (see supplemental file for acceptability question descriptive data for additional ICD10 categories). However, medical comorbidity was independently related to acceptability with higher comorbidity associated with higher acceptability scores. This suggests that patients with more chronic medical conditions were more likely to find TN more acceptable. These findings suggest that TN is useful and acceptable to patients with a variety of neurologic conditions and that more medically complex patients may find it even more acceptable. As was demonstrated in an Italian study, utilization of telemedicine in the care of complex patients with chronic conditions has the potential to bridge gaps between hospital- and home-based care [15]. Given that many neurologic conditions are associated with mobility and cognitive issues, it is important to understand the utility of and patient experience with TN when these difficulties are present. We also found no relationship between the type of virtual visit and acceptability suggesting that a variety of TN delivery methods may be useful including virtual visits at home or in a medical office closer to the patient. Although the physician perspective was not the focus of this study, NTNP-referring physicians are also highly satisfied with TN care for their patients (data not shown) [3].

One of the biggest benefits of TN is its potential to increase patient access to neurologic care. Overall, there is a mismatch between the geographic location of neurologists and patients with neurologic conditions [2]. For certain conditions like multiple sclerosis, a high proportion of patients have access to a neurologist regardless of their location, but for other conditions, like dementia, access is lower in regions with lower neurologist density [2]. This issue of access is especially relevant for rural communities where there may be no local neurologist and the closest academic center may be hours away. Over 50% of the patients who completed the survey in this study did not have access to any local neurologist within the VHA system (Table 2) and 49% of them were classified as rurally residing.

Headache is among the most prevalent chronic neurologic conditions. Compared to many neurologic conditions, headache diagnosis and treatment are less dependent on ongoing physical exams. Thus, telemedicine may be especially well-suited for the evaluation and management of patients with various types of headaches. Telemedicine for headache care has demonstrated high levels of patient satisfaction and is viewed as a viable alternative to in-person care [9]. Multiple randomized controlled studies have shown no difference in the outcome of treatment for headache or in patient satisfaction when comparing telemedicine and in-person care [10, 16,17,18,19]. Although patients in the headache category differed from the others in terms of age, sex, and visit type in our study, they did not demonstrate significantly different acceptability scores.

Movement disorders are another neurologic condition with robust literature supporting the use of TN. There have been multiple TN studies in patients with Parkinson’s disease that have been favorable towards telemedicine. For example, a 2010 study demonstrated an increase in quality of life in patients with Parkinson’s disease after telemedicine when compared to an in-person cohort [12]. Other studies have not found this increase in quality of life but have found telemedicine to be equivalent to in-person care when measured based on rates of satisfaction and patient outcome [20,21,22,23]. Telemedicine services have even been successfully initiated for the management of deep brain stimulation (DBS) and may provide a much-needed increase in access to DBS for patients with Parkinson’s disease [24]. Developments in mobile health technologies that allow monitoring of mobility in patients with neurologic disease may further improve clinical care and work in conjunction with telemedicine services such as those utilized in Parkinson’s disease [25]. Our movement disorder group included patients with multiple types of movement disorders and provides further evidence that TN is acceptable to patients with these diagnoses.

The third most common ICD10 category was symptoms. This category was used when the consulting neurologist listed a neurological symptom rather than an official diagnosis. Examples of symptoms in this category include dizziness, vision changes, and weakness. Given that ICD10 codes at the time of the first consult were used, it is possible that some of these patients in the symptoms category would eventually receive a more specific diagnosis. Nonetheless, this category is important as it demonstrates that even patients who did not have a definitive diagnosis at the close of their initial neurology consultation were largely satisfied and found their TN visit to be acceptable. There are many patients who have an apparent neurologic symptom of unknown cause. It is valuable to understand what their experience with TN is and how it compares to patients with a known diagnosis.

This study is not without limitations. We were not able to statistically compare acceptability scores across a wide range of ICD10 groups due to the small sample size in some of the categories. However, as can be seen in supplemental file Table 2, the data demonstrates similar acceptability ratings across the different ICD10 groups which suggests that neurologic diagnosis is not a major driver of how likely patients are to accept TN. The distribution of diagnoses in this sample is similar to that seen in referrals to non-VA neurologists at these facilities (data not shown), suggesting that the patients receiving TN care have similar proportions of diagnosis groups as those being referred for in-person care. Reflecting the Veteran population, there were fewer female Veterans and most patients were White, which to some extent reflects the focus of NTNP on rural areas as well as those with reduced neurology access in general. Although this might limit the generalizability of our study, no differences in acceptability relative to race were found. Another limitation is that this data is based on the patient’s first visit with a neurologist. Thus, the diagnosis they receive and their experience may evolve as further follow-up and diagnostic work-up is obtained. Finally, this study does not reflect the experience of the referring provider with Teleneurology care, although our surveys of primary care providers have shown high levels of satisfaction with the NTNP program (data not shown); this is perhaps not surprising in settings with little access to specialty neurology care and considering that VA Teleneurology care uses the same electronic health record as the referring provider, thus limiting communication difficulties across healthcare systems.

In summary, this study demonstrated that patients with different neurologic conditions found their TN experience quite acceptable and that this acceptability was independent of diagnosis but was related to medical comorbidity as patients with higher comorbidities reported higher acceptance of TN care. This suggests that TN care is acceptable to patients with neurologic conditions and symptoms and may be especially acceptable to medically complex patients. Future studies should further evaluate patient experience with TN care to include follow-up care and to examine differences in management and outcomes compared to in-person care.