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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 648-649

Redefining neurology care at outpatient services of tertiary hospitals: Case for paradigm shift from tertiary to peripheral centers


Department of Neurology, Institute of Human Behaviour and Allied Sciences; Department of Neurophysiology and Neurology, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. M Gourie-Devi
Department of Neurology, Institute of Human Behaviour and Allied Sciences, PO Box 9520, Dilshad Garden, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263257

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How to cite this article:
Gourie-Devi M. Redefining neurology care at outpatient services of tertiary hospitals: Case for paradigm shift from tertiary to peripheral centers. Neurol India 2019;67:648-9

How to cite this URL:
Gourie-Devi M. Redefining neurology care at outpatient services of tertiary hospitals: Case for paradigm shift from tertiary to peripheral centers. Neurol India [serial online] 2019 [cited 2019 Aug 25];67:648-9. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/648/263257




India is in an epidemiological transition, with the persistence of some communicable diseases, newly emerging infections, a remarkable increase in the incidence of non-communicable disorders, and the effect of climatic change on the prevalence and pattern of diseases.[1],[2] The burden of neurological disorders, apart from the vast number of disorders of the central and peripheral nervous system, would obviously also include the consequences of nervous system invasion by infections as well as traumatic injuries. The challenges to the neurologist in a busy public or private hospital or in specialty clinics are thus multifold. Population based house-to-house surveys of urban and rural population in different regions of the country have revealed the prevalence rate of spectrum of neurological disorders varying from 967 to 4070, with a mean of 2394 per 100000 population.[3],[4],[5],[6],[7],[8],[9],[10] These were 'two stage' surveys. In the first stage, the non-medical field workers administered the questionnaire; and in the second stage, the screened-positive subjects were examined by the neurologist.[11],[12] It is quite evident that the prevalence rates of neurological disorders through community surveys mentioned above represent only a fraction of the magnitude of burden of neurological diseases since the vast number of neurological infections and traumatic injuries were not included due to feasibility issues.

The authors of the paper “Outpatient burden of neurological disorders: A prospective evaluation of 1500 patients” published in the current issue, have made some significant and pertinent observations.[13] The prevalence rates of common neurological disorders in the descending order of frequency were headache, epilepsy, cerebrovascular disorders and neuropathy, the first two disorders accounting for 40% of all neurological disorders seen in the outpatient department of a tertiary hospital during a period of 2 months. It is noteworthy that in community based surveys also, headache and epilepsy had a high prevalence rate and together accounted for 40 to 75% of all neurological disorders.[3],[4],[5],[6],[7],[8],[9],[10] Having defined the burden of two common neurological disorders at the community level and at the outpatient level of a tertiary hospital, pathways of care need to be developed to reduce the burden on tertiary hospitals, to enable the latter to concentrate on complex disorders. Models of neurological care with multisectoral involvement is the need of the hour. Similar to other diseases, either a 'top-down approach' (centre to periphery), a 'bottom-up' approach (periphery to centre), or a 'co-ordinated approach' may be considered.[14],[15] Training of health professionals at the periphery by imparting knowledge and skills by experts, an inbuilt system of monitoring, feedback from the periphery to the centre, and introducing midcourse remedial measures, are some of the essential components of these strategies for delivery of health care. These issues were also addressed in the development of 'district model of epilepsy care' by the author and colleagues, and was found to be successful in the diagnosis and management of epilepsy.[16] It would be quite feasible to include headache, stroke and peripheral neuropathies in this model. The alternate model is to establish 'satellite clinics' attached to the tertiary centers, which will facilitate the decentralisation and development of resources at the peripheral levels of neurology care.[14] A multipronged approach, hopefully, in a reasonable time frame may transform the scenario of neurology care in the country.



 
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National commission on macroeconomics and health. Burden of disease in India. Ministry of Health and Family Welfare, Government of India, New Delhi, 2005. Available from: https://www.who.int/macrohealth/action/Report%20of%20th e%20National%20Commission.pdf. [Last accessed on 2019 Jun 26].  Back to cited text no. 1
    
2.
Indian Council of Medical Research, High Power Committee Report. https://www.icmr.nic.in/content/high-power-committee, 2014.  Back to cited text no. 2
    
3.
Gourie-Devi M. Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy, stroke, Parkinson's disease and tremors. Neurol India 2014;62:588-98.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Gourie-Devi M, Rao VN, Prakashi R. Neuroepidemiological study in semiurban and rural areas in South India: Pattern of neurological disorders including motor neurone disease. In: Gourie-Devi M, editor. Motor Neurone Disease: Global Clinical Patterns and International Research. New Delhi: Oxford and India Book House; 1987. p. 11-21.  Back to cited text no. 4
    
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Kapoor SK, Banerjee AK. Prevalence of common neurological diseases in a rural community of India. Indian J Community Med 1989;14:171-6.  Back to cited text no. 5
    
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Razdan S, Kaul RL, Motta A, Kaul S, Bhatt RK. Prevalence and pattern of major neurological disorders in rural Kashmir (India) in 1986. Neuroepidemiology 1994;13:113-9.  Back to cited text no. 6
    
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Das SK, Sanyal K. Neuroepidemiology of major neurological disorders in rural Bengal. Neurol India 1996;44:47-58.  Back to cited text no. 7
[PUBMED]    
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Saha SP, Bhattacharya S, Das SK, Maity B, Roy T, Raut DK. Epidemiological study of neurological disorders in a rural population of Eastern India. J Indian Med Assoc 2003;101:299-304.  Back to cited text no. 8
    
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Gourie-Devi M, Gururaj G, Satishchandra P, Subbakrishna DK. Prevalence of neurological disorders in Bangalore, India: A community-based study with a comparison between urban and rural areas. Neuroepidemiology 2004;23:261-68.  Back to cited text no. 9
    
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Das SK, Biswas A, Roy T, Banerjee TK, Mukherjee CS, Raut DK et al. A random sample survey for prevalence of major neurological disorders in Kolkota. Indian J Med Res 2006;124:163-72.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
World Health Organisation. Research protocol for measuring the prevalence of neurological disorders in developing countries. Neurosciences programme, World Health Organisation, Geneva, 1981. Available from: https://apps.who.int/iris/handle/10665/72410. [Last accessed on 2019 Jun 26].  Back to cited text no. 11
    
12.
Gourie-Devi M, Gururaj G, Satishchandra P, Subbakrishna DK. Neuroepidemiological pilot survey of an urban population in a developing country. A study in Bangalore, South India. Neuroepidemiology 1996;15:313-20.  Back to cited text no. 12
    
13.
Nandig R, Namapally US, Sarma GR, Mathew T. Out patient burden of neurological disorders: A prospective evaluation of 1500 patients. Neurol India 2019:67:708-13.  Back to cited text no. 13
    
14.
Gourie-Devi M. Organization of neurology services in India: Unmet needs and the way forward. Neurol India 2008;56:4-12.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Ogunlayi F, Britton P. Achieving a 'top-down' change agenda by driving and supporting a collaborative 'bottom-up' process: Case study of a large-scale enhanced recovery programme. BMJ Open Qual 2017;6:e000008.  Back to cited text no. 15
    
16.
Gourie-Devi M, Satishchandra P, Gururaj G. Epilepsy in primary care. Epilepsy control program in India: A district model. Epilepsia 2003;44(Suppl. 1):58-62.  Back to cited text no. 16
    




 

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