Disruptions of neurological services, its causes and mitigation strategies during COVID-19: a global review

DOI: https://doi.org/10.1007/s00415- 021- 10588- 5

Abstract-Summary The COVID-19 pandemic leads to disruptions of health services worldwide.

To evaluate the particular impact on neurological services a rapid review was

conducted.

Studies reporting the provision of neurological services during the pandemic

and/or adopted mitigation strategies were included in this review.

Data extraction followed categories used by WHO COVID-19 pulse surveys and

operational guidelines on maintaining essential health services during COVID-19. Cross-sectoral services for neurological disorders were most frequently dis-

rupted (62.9%), followed by emergency/acute care (47.1%).

Travel restrictions due to lockdowns (81.7%) and regulatory closure of services

(65.4%) were the most commonly reported causes of disruption.

The COVID-19 pandemic affects all aspects of neurological care. Given the worldwide prevalence of neurological disorders and the potential long- term neurological consequences of COVID-19, service disruptions are devastating. Different strategies such as telemedicine might mitigate the negative effects of

the pandemic, but their efficacy and acceptability remain to be seen.

Extended: The COVID-19 pandemic has severely affected all aspects of care of patients with neurological disorders, be it in acute, post-acute, or long-term settings, diagnostic, therapeutic, or rehabilitative.

To evaluate the impact of the COVID-19 pandemic on disruptions of neurologi- cal services and the implemented mitigation strategies, WHO commissioned this rapid review on the topic.

Data extraction followed the same categories of services, causes for disruption, and mitigation strategies as used by WHO’s COVID-19 Pulse Surveys, the Rapid Assessment of MNS services as well as WHO’s operational guidelines on maintain- ing essential health services during COVID-19 (chapter on MNS disorders) [360, 361], with additional delineations as and when necessary.

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Background A rapid assessment of MNS services conducted by WHO with 130 Ministries of Health worldwide during June–August 2020 highlighted the disruption of essential MNS services in most countries [360].

While the rapid assessment did not specifically focus on neurological services (in fact, often information on neurological services was not readily available to Ministries of Health despite the fact that neurological disorders, including dementia and stroke, represent the leading cause of disability-adjusted life years [362, 363]), it nevertheless demonstrated that surgery for neurological patients was disrupted in 1 out of 3 countries, emergency care for neurological patients was at least slightly disrupted, and outpatient neurological care was severely disrupted in most countries. We conducted a rapid review of the published evidence regarding the impact of the COVID-19 pandemic on disruptions of neurological services and the mitigation strategies implemented for the care of patients with neurological disorders.

Materials and Methods We extracted whether the study described any degree of interruption of the following categories: (1) emergency and acute care for neurological disorders; (2) investiga- tions (including neuroimaging, neurophysiology, lab diagnostics, and others); (3) treatment and care for neurological disorders (including interventions and therapies, such as planned surgeries and access to medicines); (4) neurorehabilitation, inclusive of physiotherapy, speech therapy, occupational therapy, cognitive rehabilitation, and psychology/counselling; (5) cross-sectoral service delivery for neurological disor- ders, including community-based services, residential long-term care, adult/child day care, special/inclusive school educational programmes for children, interventions for caregivers, and services/programmes delivered by non-governmental organizations; (6) promotion of brain health and prevention of neurological disorders, in addition to implementation activities of national prevention plan and neurology advocacy; (7) training of residents, PhD students or other educational activities; (8) research.

Since this review was not focused on the results of a therapeutic or diagnostic intervention, whenever any information regarding service disruption or mitigation strategies was present, the study was included in the review.

Results The most frequent study design was cross-sectional (n = 103, 27.9% publications), followed by the description of an implemented protocol (n = 99, 26.8%), before– after studies (n = 97, 26.3%), case series (n = 57, 15.4%), prospective cohort studies (n = 10, 2.7%), and retrospective cohort studies (n = 3, 0.8%).

The most frequently reported disruptions occurred for cross-sectoral service delivery for neurological disorders, which was assessed in 151 of 240 studies (62.9%), followed by emergency and acute care for neurological disorders (n = 113, 47.1%), and treatment and care for neurological disorders (n = 109, 45.4%).

The degree of disruption of neurological services was described in 188 studies and was most frequently classified as moderate disruption (n = 131, 69.7%), fol- lowed by mild disruption (n = 40, 21.3%), severe disruption (n = 10, 5.3%), and non-disrupted (n = 7, 3.7%).

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Discussion This is the first global review of the published evidence regarding the impact the COVID-19 pandemic on the care for people with neurological disorders and the mitigation strategies put in place at policy, system, service level to compensate for service disruptions.

Service disruptions were particular prominent in cross-sectoral service delivery and emergency and acute neurology care, which was supported by more than 100 studies from different countries and health care system scenarios.

More than 75% of these studies indicated severe disruption of essential services in acute care—the result of the emerging impact of the first wave of pandemic in different areas of the world.

There were many publications focusing on guidance and recommendations about what to do in terms of alleviating and mitigating the disruption of the neurological services [364, 365], but little consensus on which items should be included in stud- ies systematically evaluating this topic and how the results should be presented.

Conclusion The COVID-19 pandemic has severely affected all aspects of care of patients with neurological disorders, be it in acute, post-acute, or long-term settings, diagnostic, therapeutic, or rehabilitative.

The impact of the pandemic on neurological services and neurological disorders may be explained by travel restrictions for patients, fear of infections or closure of inpatient and outpatient services as per health authority directive, amongst others.

Authors described various potential strategies to mitigate the effects of the pan- demic, with telemedicine being the most frequently used mitigation strategy but evidence of their effectiveness in managing neurological disorders remains largely lacking.

Acknowledgement A machine generated summary based on the work of García-Azorín, David; Seeher, Katrin M.; Newton, Charles R.; Okubadejo, Njideka U.; Pilotto, Andrea; Saylor, Deanna; Winkler, Andrea Sylvia; Charfi Triki, Chahnez; Leonardi, Matilde 2021 in Journal of Neurology.

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