# Mind the gap: a German case study on the discrepancy between geographic accessibility and real-world utilization of botulinum toxin therapy

## TL;DR

This study explores why many German patients do not receive botulinum toxin therapy despite good access to treatment centers.

## Contribution

The study identifies structural and economic barriers to botulinum toxin therapy in Germany, even with high geographic accessibility.

## Key findings

- 96.72% of the German population lives within 60 minutes of a BoNT-A center.
- Only 30.2% of invited physicians completed the survey, with 79.6% working in neurology.
- Structural and economic barriers, not access, hinder BoNT-A therapy use in Germany.

## Abstract

Botulinum toxin A (BoNT-A) is widely used in the treatment of neurological disorders. Despite guideline recommendations, particularly regarding BoNT-A injections for post-stroke spasticity, current evidence shows that many patients in Germany do not receive BoNT-A therapy.

An analysis of travel time to neurological Botulinum Toxin (BoNT-A) centers was conducted based on German hospital quality reports. Additionally, the German Botulinum Toxin Working Group (Arbeitskreis Botulinumtoxin e. V.; AK-BoNT) performed an anonymous online survey of its members, who treat with BoNT, between November 2023 and March 2024 to document experiences, identify perceived barriers, and explore potential improvements in BoNT-A therapy.

The geospatial analysis showed theoretical accessibility to specialized neurological BoNT−A centers in Germany with 96.72% of the population residing within a 60-min drive of a qualified facility. Of 632 invited AK-BoNT members, 191 completed the survey in full (30.2% response rate). 79.6% of the respondents worked in neurology and two thirds of the respondents had more than 10 years of experience with BoNT-A. Although more than 60% of respondents rated BoNT-A therapy as effective regardless of indication, many pointed to structural and economic barriers, including inadequate reimbursement pathways and limited multidisciplinary collaboration.

The results indicate that BoNT-A is recognized and provides therapeutic benefit from the perspective of the treating physician, but structural and economic barriers hinder the use of this therapy. Interestingly, even in a well-resourced system with broad geographic access to specialized care, significant treatment gaps may persist. Recommendations include standardized reimbursement structures, improved education, and increased cross-sector collaboration.