title: Availability, accessibility, and affordability of neurodiagnostic tests in 37 countries.
abstract: OBJECTIVE
  To determine the availability, accessibility, and affordability of EEG, EMG, CSF analysis, head CT, and brain MRI for neurologic disorders across countries.
  
  
  METHODS
  An online, 60-question survey was distributed to neurology practitioners in 2014 to assess the presence, wait time, and cost of each test in private and public health sectors. Data were stratified by World Bank country income group. Affordability was calculated with reference to the World Health Organization's definition of catastrophic health expenditure as health-related out-of-pocket expenditure of >40% of disposable household income, and assessment of providers' perceptions of affordability to the patient.
  
  
  RESULTS
  Availability of EEG and EMG is correlated with higher World Bank income group (correlation coefficient 0.38, test for trend p = 0.046; 0.376, p = 0.043); CSF, CT, and MRI did not show statistically significant associations with income groups. Patients in public systems wait longer for neurodiagnostic tests, especially MRI, EEG, and urgent CT (p < 0.0001). The mean cost per test, across all tests, was lower in the public vs private sector (US $55.25 vs $214.62, p < 0.001). Each drop in World Bank income group is associated with a 29% decrease in the estimated share of the population who can afford a given test (95% confidence interval -33.4, 25.2; p < 0.001). In most low-income countries surveyed, only the top 10% or 20% of the population was able to afford tests below catastrophic levels. In surveyed lower-middle-income countries, >40% of the population, on average, could not afford neurodiagnostic tests.
  
  
  CONCLUSIONS
  Neurodiagnostic tests are least affordable in the lowest income settings. Closing this "diagnostic gap" for countries with the lowest incomes is essential.
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Hannah C
authors.initials: HC
authors.lastname: McLane
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Aaron L
authors.initials: AL
authors.lastname: Berkowitz
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Bryan N
authors.initials: BN
authors.lastname: Patenaude
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Erica D
authors.initials: ED
authors.lastname: McKenzie
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Emma
authors.initials: E
authors.lastname: Wolper
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Wahlster
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA.
authors.forename: Günther
authors.initials: G
authors.lastname: Fink
authors.affiliation: From the Department of Neurology (H.C.M.), University of Pennsylvania, Philadelphia; Harvard Medical School (A.L.B., S.W., F.J.M.), Boston; Department of Neurology (A.L.B., S.W.), Brigham & Women's Hospital, Boston; Harvard T.H. Chan School of Public Health (B.N.P., G.F.), Boston; Department of Neurology (E.D.M., E.W., S.W., F.J.M.), Massachusetts General Hospital, Boston; School of Medicine (E.D.M.), Queen's University, Kingston, Canada; and Lesley University (E.W.), Cambridge, MA. fmateen@partners.org.
authors.forename: Farrah J
authors.initials: FJ
authors.lastname: Mateen
mesh_terms: D002555:Cerebrospinal Fluid; D003943:Diagnostic Techniques, Neurological / Q000191:economics / Q000706:statistics & numerical data*; D004569:Electroencephalography / Q000191:economics / Q000706:statistics & numerical data; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007182:Income; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000706:statistics & numerical data*; D059906:Neuroimaging / Q000191:economics / Q000706:statistics & numerical data; D017149:Private Sector / Q000191:economics / Q000706:statistics & numerical data; D017150:Public Sector / Q000191:economics / Q000706:statistics & numerical data; D013129:Spinal Puncture / Q000191:economics / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000706:statistics & numerical data*; D014480:United Nations; D014944:World Health Organization