Aiming to improve virtual encounters for epilepsy

By Richard Mark Kirkner

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As more health interventions move to a virtual platform because of COVID-19, researchers have reported that virtual interactions in a program designed to help epilepsy patients self-manage cognitive dysfunction didn’t improve patient outcomes to the extent that in-person office visits did.

Results of the trial were presented online as part of the 2020 American Academy of Neurology Science Highlights.

“As we found, the virtual visits were less effective than in-person delivery,” said senior author Barbara C. Jobst, MD, PhD, director of the Dartmouth-Hitchcock Epilepsy Center and the Epilepsy Cognition Lab at the Geisel School of Medicine at Dartmouth, Hanover, N.H. “That means there is something to the in-person interaction, and if we do this interaction virtually, we have to think about how we structure this.”

The trial enrolled 108 adults with epilepsy from four clinical sites across northern New England. They were randomized to either participate in Home-Based Self-management and Cognitive Training Changes Lives (HOBSCOTCH) in-person (n = 20) or virtually (n = 17), or a 6-month wait-list control period (n = 48). 

HOBSCOTCH is a behavior program that the Managing Epilepsy Well (MEW) network developed to help adults with epilepsy manage their memory issues. Other MEW programs include PACES (Program of Active Consumer Engagement in Self-Management in Epilepsy), which emphasizes emotional and community adjustment, and Project UPLIFT (Using Practice and Learning to Increase Favorable Thoughts) for depression.

Dr. Barbara C. Jobst

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HOBSCOTCH is an 8- to 12-session program that assigns patients a memory coach for weekly or biweekly sessions. The first and last sessions are in person, with the intervening sessions over the phone or virtually. The initial session is a primer on memory problems in epilepsy as well as an opportunity for the patient to get to know her or his memory coach.

The Dartmouth-Hitchcock group replaced the first and last in-person visits with virtual encounters via the Webex videoconferencing application for 17 patients in the virtual group. Dr. Jobst noted that the structure and content of the first and last sessions were identical for the in-person and virtual groups.

In the trial, the in-person group members improved their quality of life score an average of 12.4 points (P < .001), on a scale of 0-31, Dr. Jobst said. Their subjective cognition total score improved 6.2 points on average (P < .001). However, the virtual group had no statistically significant improvements versus controls. The trial was completed before COVID-19 pandemic restrictions took effect.

In a comparison of the two HOBSCOTCH groups, the in-person patients showed improvements in self-reported cognition versus virtual (P = .01), and an overall quality of life 6.7 points higher than the control group, although that result wasn’t considered statistically significant.

A within-group analysis found overall QOL improvements from baseline for both in-person (P = .002) and virtual (P = .023) groups. In-person HOBSCOTCH improved in subjective cognition (P = .0001) while the virtual group did not. The control group had no change during this period.

“What this tells us is that the personal relationship is important in care,” Dr. Jobst said. “Doing something on the screen is not the same as having the person in the room.”

Dr. Jobst acknowledged advantages to having effective virtual encounters, not only because COVID-19 has discouraged many patients from physically visiting practitioners’ office, but also because much of the territory the Dartmouth-Hitchcock Epilepsy Center covers is remote and difficult for patients to travel, especially during harsh winter months.

“We’re now trying to work on how we can establish that relationship in a better way virtually,” Dr. Jobst said. “That’s our next study.” That would involve an extra virtual session in which the memory coach and patient develop a personal relationship. “It’s really important that the epilepsy community is aware of these self-management programs and also that they have access to them,” she added.

Dr. Jobst and colleagues have no financial relationships to disclose.

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