Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic

This study describes trends in use of in-person, telephone, and video primary care and behavioral health visits to California Federally Qualified Health Centers from 2019 to August 2020 before and during the coronavirus disease 2019 (COVID-19) pandemic.

Covid-19 driven advances in automation and artificial intelligence risk exacerbating economic inequality

Anton Korinek and Joseph E Stiglitz make the case for a deliberate effort to steer technological advances in a direction that enhances the role of human workers

[Home telemonitoring and oxygen therapy in COVID-19 patients: safety, patient satisfaction, and cost-effectiveness]

OBJECTIVE

To evaluate the implementation of home telemonitoring and oxygen therapy in COVID-19 patients. Primary outcomes were safety, patient satisfaction, reduction of hospital stay, and cost-effectiveness.

DESIGN

Retrospective cohort study.

METHOD

All COVID-19 patients who were discharged with home telemonitoring and oxygen therapy between June 1st and November 1st 2020 were included. Eligible patients had a maximum oxygen requirement of 2 liters per minute during the 24 hours prior to discharge with a minimal peripheral oxygen saturation of 94%. A mobile application for telemonitoring was used, which patients or relatives had to be able to use independently. Patient demographics, clinical parameters, data on telemonitoring and readmissions were extracted from the electronic patient records. A survey for patient satisfaction and a cost-effectiveness analysis were performed.

RESULTS

Out of 619 admissions, 49 patients were discharged with home telemonitoring and oxygen therapy. Median duration of home oxygen therapy was 11 days with a potential reduction in hospitalization of 616 days. Six patients were readmitted and were significantly more febrile on discharge (67% versus 14%, p=0.01) and had lower oxygenation (95%, (IQR 93-96) versus 96%, (IQR 95-97), p=0.02) with similar levels of oxygen administration. Patient satisfaction was high with a mean score of 5 to 6 on a scale measuring satisfaction from 1 to 7. Estimated total cost reduction was € 146.736.

CONCLUSION

This study shows that home telemonitoring and oxygen administration can be safely applied in COVID-19 patients resulting in a high patient satisfaction and reduction in hospital stay and costs.

Cost-effectiveness of a Telemonitoring Program for Patients With Heart Failure During the COVID-19 Pandemic in Hong Kong: Model Development and Data Analysis

BACKGROUND

The COVID-19 pandemic has caused patients to avoid seeking medical care. Provision of telemonitoring programs in addition to usual care has demonstrated improved effectiveness in managing patients with heart failure (HF).

OBJECTIVE

We aimed to examine the potential clinical and health economic outcomes of a telemonitoring program for management of patients with HF during the COVID-19 pandemic from the perspective of health care providers in Hong Kong.

METHODS

A Markov model was designed to compare the outcomes of a care under COVID-19 (CUC) group and a telemonitoring plus CUC group (telemonitoring group) in a hypothetical cohort of older patients with HF in Hong Kong. The model outcome measures were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the model assumptions and the robustness of the base-case results.

RESULTS

In the base-case analysis, the telemonitoring group showed a higher QALY gain (1.9007) at a higher cost (US $15,888) compared to the CUC group (1.8345 QALYs at US $15,603). Adopting US $48,937/QALY (1 × the gross domestic product per capita of Hong Kong) as the willingness-to-pay threshold, telemonitoring was accepted as a highly cost-effective strategy, with an incremental cost-effective ratio of US $4292/QALY. No threshold value was identified in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis, telemonitoring was accepted as cost-effective in 99.22% of 10,000 Monte Carlo simulations.

CONCLUSIONS

Compared to the current outpatient care alone under the COVID-19 pandemic, the addition of telemonitoring-mediated management to the current care for patients with HF appears to be a highly cost-effective strategy from the perspective of health care providers in Hong Kong.

Payer strategies to ensure access to care for individuals with opioid use disorder during COVID-19

As the coronavirus disease 2019 (COVID-19) pandemic threatens to worsen the opioid crisis, payers must rapidly deploy policies to ensure care for individuals with opioid use disorder.

In-Person and Telehealth Ambulatory Contacts and Costs in a Large US Insured Cohort Before and During the COVID-19 Pandemic

IMPORTANCE

This study assesses the role of telehealth in the delivery of care at the start of the COVID-19 pandemic.

OBJECTIVES

To document patterns and costs of ambulatory care in the US before and during the initial stage of the pandemic and to assess how patient, practitioner, community, and COVID-19-related factors are associated with telehealth adoption.

DESIGN, SETTING, AND PARTICIPANTS

This is a cohort study of working-age persons continuously enrolled in private health plans from March 2019 through June 2020. The comparison periods were March to June in 2019 and 2020. Claims data files were provided by Blue Health Intelligence, an independent licensee of the Blue Cross and Blue Shield Association. Data analysis was performed from June to October 2020.

MAIN OUTCOMES AND MEASURES

Ambulatory encounters (in-person and telehealth) and allowed charges, stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code.

RESULTS

A total of 36 568 010 individuals (mean [SD] age, 35.71 [18.77] years; 18 466 557 female individuals [50.5%]) were included in the analysis. In-person contacts decreased by 37% (from 1.63 to 1.02 contacts per enrollee) from 2019 to 2020. During 2020, telehealth visits (0.32 visit per person) accounted for 23.6% of all interactions compared with 0.3% of contacts in 2019. When these virtual contacts were added, the overall COVID-19 era patient and practitioner visit rate was 18% lower than that in 2019 (1.34 vs 1.64 visits per person). Behavioral health encounters were far more likely than medical contacts to take place virtually (46.1% vs 22.1%). COVID-19 prevalence in an area was associated with higher use of telehealth; patients from areas within the top quintile of COVID-19 prevalence during the week of their encounter were 1.34 times more likely to have a telehealth visit compared with those in the lowest quintile (the reference category). Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates). Per enrollee medical care costs decreased by 15% between 2019 and 2020 (from $358.32 to $306.04 per person per month). During 2020, those with 1 or more COVID-19-related service (1 470 721 members) had more than 3 times the medical costs ($1701 vs $544 per member per month) than those without COVID-19-related services. Persons with 1 or more telehealth visits in 2020 had considerably higher costs than persons having only in-person ambulatory contacts ($2214.10 vs $1337.78 for the COVID-19-related subgroup and $735.87 vs $456.41 for the non-COVID-19 subgroup).

CONCLUSIONS AND RELEVANCE

This study of a large cohort of patients enrolled in US health plans documented patterns of care at the onset of COVID-19. The findings are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the pandemic and afterward.

Cost-effectiveness of a telehealth intervention for in-home dementia care support: Findings from the FamTechCare clinical trial

Determining the cost-effectiveness of technological interventions is a crucial aspect in assuring these interventions can be adopted. The FamTechCare intervention is an innovative telehealth support that links family caregivers of persons living with dementia to tailored feedback from dementia care experts based on caregiver-initiated video recordings of challenging care situations. The FamTechCare intervention has demonstrated significant reductions in caregiver depression and increases in caregiver competence when compared to standard telephone support. The purpose of this article is to report on the cost-effectiveness of the FamTechCare telehealth intervention. Process-based costing and a cost-effectiveness analysis using the incremental cost-effectiveness ratio (ICER) was completed with 68 caregiver and person living dementia with dyads. The cost of the 12-week FamTechCare telehealth intervention was found to be greater ($48.43 per dyad per week) due to the telehealth equipment, recording application, and expert panel time compared with the telephone support intervention ($6.96 per dyad per week). The ICER was $18.51 for caregiver depression and $36.31 for caregiver competence indicating that it cost no more than $36.38 per dyad per week over 12 weeks to achieve significant improvement in depression and competence in the FamTechCare caregivers compared to the telephone support caregivers. The FamTechCare intervention appears to be cost-effective when compared to the telephone support intervention and remains near the willingness-to-pay threshold for caregivers providing in-home dementia care support.

Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol

BACKGROUND

One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care.

METHODS

eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness.

DISCUSSION

To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Assessing the use of cell phones to monitor health and nutrition interventions: Evidence from rural Guatemala

In-person (face-to-face) data collection methods offer many advantages but can also be time-consuming and expensive, particularly in areas of difficult access. We take advantage of the increasing mobile phone penetration rate in rural areas to evaluate the feasibility of using cell phones to monitor the provision of key health and nutrition interventions linked to the first 1,000 days of life, a critical period of growth and development. We examine response rates to calendarized text messages (SMS) and phone calls sent to 1,542 households over a period of four months. These households have children under two years old and pregnant women and are located across randomly selected communities in Quiche, Guatemala. We find that the overall (valid) response rate to phone calls is over 5 times higher than to text messages (75.8% versus 14.4%). We also test whether simple SMS reminders improve the timely reception of health services but do not find any effects in this regard. Language, education, and age appear to be major barriers to respond to text messages as opposed to phone calls, and the rate of response is not correlated with a household’s geographic location (accessibility). Moreover, response veracity is high, with an 84–91% match between household responses and administrative records. The costs per monitored intervention are around 1.12 US dollars using text messages and 85 cents making phone calls, with the costs per effective answer showing a starker contrast, at 7.76 and 1.12 US dollars, respectively. Our findings indicate that mobile phone calls can be an effective, low-cost tool to collect reliable information remotely and in real time. In the current context, where in-person contact with households is not possible due to the COVID-19 crisis, phone calls can be a valuable instrument for collecting information, monitoring development interventions, or implementing brief surveys.

A telephone-based surgical transitional care program with improved patient satisfaction scores and fiscal neutrality

BACKGROUND

Limited data exist regarding the downstream effects of surgical transitional care programs. We explored the impact of such programs on patient satisfaction and fiscal metrics.

METHODS

A telephone-based surgical transitional care program enrolled patients undergoing complex abdominal surgery between 2015 to 2017. A matched cohort undergoing similar procedures between 2010 to 2015 were used as controls. Press Ganey scores were used to reflect patient satisfaction. Hospital costs, reimbursements, and margins were analyzed for index hospitalizations and readmissions within 90 days of surgery.

RESULTS

There were 607 patients in the control group and 608 in the transitional care program; survey response rates were 37% and 35%, respectively. Transitional care patients rated their understanding of personal responsibilities in post-discharge care higher than controls (59% vs 69%, P = .02). Transitional care patients felt they received better educational materials about their condition or treatment (55% vs 68%, P < .01) and rated their global hospital experience higher (46% vs 57%, P = .02). The aggregate (index plus readmission) cost was greater for the transitional care ($22,814 vs $25,827, P < .01), but there was no difference in aggregate margin ($7,027 vs $4,698, P = .25). Multivariable adjustment yielded similar results for the aggregate cost (ref vs $2,232, P = .03) and margin (ref vs $1,299, P = .23).

CONCLUSION

The use of this dedicated abdominal surgery transitional care program is associated with improved Press Ganey patient education and global rating scores. The cost to support this program did not adversely affect the hospital margin when considering all factors. These data support broader investment in patient centered initiatives that may significantly enhance patient experience.

Identifying the Value of an eHealth Intervention Aimed at Cognitive Impairments: Observational Study in Different Contexts and Service Models

BACKGROUND

Value is one of the central concepts in health care, but it is vague within the field of summative eHealth evaluations. Moreover, the role of context in explaining the value is underexplored, and there is no explicit framework guiding the evaluation of the value of eHealth interventions. Hence, different studies conceptualize and operationalize value in different ways, ranging from measuring outcomes such as clinical efficacy or behavior change of patients or professionals to measuring the perceptions of various stakeholders or in economic terms.

OBJECTIVE

The objective of our study is to identify contextual factors that determine similarities and differences in the value of an eHealth intervention between two contexts. We also aim to reflect on and contribute to the discussion about the specification, assessment, and relativity of the "value" concept in the evaluation of eHealth interventions.

METHODS

The study concerned a 6-month eHealth intervention targeted at elderly patients (n=107) diagnosed with cognitive impairment in Italy and Sweden. The intervention introduced a case manager role and an eHealth platform to provide remote monitoring and coaching services to the patients. A model for evaluating the value of eHealth interventions was designed as monetary and nonmonetary benefits and sacrifices, based on the value conceptualizations in eHealth and marketing literature. The data was collected using the Mini-Mental State Examination (MMSE), the clock drawing test, and the 5-level EQ-5D (EQ-5D-5L). Semistructured interviews were conducted with patients and health care professionals. Monetary data was collected from the health care and technology providers.

RESULTS

The value of an eHealth intervention applied to similar types of populations but differed in different contexts. In Sweden, patients improved cognitive performance (MMSE mean 0.85, SD 1.62, P<.001), reduced anxiety (EQ-5D-5L mean 0.16, SD 0.54, P=.046), perceived their health better (EQ-5D-5L VAS scale mean 2.6, SD 9.7, P=.035), and both patients and health care professionals were satisfied with the care. However, the Swedish service model demonstrated an increased cost, higher workload for health care professionals, and the intervention was not cost-efficient. In Italy, the patients were satisfied with the care received, and the health care professionals felt empowered and had an acceptable workload. Moreover, the intervention was cost-effective. However, clinical efficacy and quality of life improvements have not been observed. We identified 6 factors that influence the value of eHealth intervention in a particular context: (1) service delivery design of the intervention (process of delivery), (2) organizational setup of the intervention (ie, organizational structure and professionals involved), (3) cost of different treatments, (4) hourly rates of staff for delivering the intervention, (5) lifestyle habits of the population (eg, how physically active they were in their daily life and if they were living alone or with family), and (6) local preferences on the quality of patient care.

CONCLUSIONS

Value in the assessments of eHealth interventions need to be considered beyond economic terms, perceptions, or behavior changes. To obtain a holistic view of the value created, it needs to be operationalized into monetary and nonmonetary outcomes, categorizing these into benefits and sacrifices.

Employee and Employer Benefits From a Migraine Management Program: Disease Outcomes and Cost Analysis

OBJECTIVE

To assess the impact of a migraine management program offered as a complimentary service by a company within its corporate well-being program.

BACKGROUND

Migraine imposes a substantial burden on patients, families, employers, and societies. As migraine primarily affects working-age adults, this has important implications for both employees and employers. Workplace educational and well-being programs positively contribute to employees' productivity, reduce costs related to absenteeism, and improve the quality of life of the employees living with migraine.

METHODS

This was a non-interventional cohort study, which followed employees and their family members over time. Participants received 1 telemedicine consultation to determine migraine diagnosis or a high probability of having migraine and 6 sessions of individualized telecoaching from a specialized nurse via a specially developed smartphone application to optimize their migraine management leveraging all appropriate medical and lifestyle options. Participants were evaluated during the program and at 3 months after completion through a series of validated questionnaires including Migraine Disability Assessment (MIDAS), Patient Activation Measure (PAM), and satisfaction with the services offered. A cost analysis was also performed to determine the economic benefit of the program considering the number of completers, dropouts, their associated program costs, MIDAS data, average salary of a Swiss employee in the pharma sector, and working days per year.

RESULTS

Of the 141 participants enrolled in the program, 79 completed 6-month and 42 completed 9-month assessments. The total MIDAS scores (mean, standard deviation [SD]) significantly improved from baseline by 54% at Month 6 (15.0 [13.6] vs 6.9 [8.2]; mean [SD] reduction: 8.1 [12.9], 95% confidence interval [CI]: 5.6-10.6; P < .0001) and by 64% at Month 9 (15.4 [14.7] vs 5.6 [6.0]; mean [SD] reduction: 9.8 [14.0], 95% CI: 6.6-13.0; P < .0001). The PAM scores also significantly improved from baseline by 8% at Month 6 (63.8 [10.9] vs 69.6 [12.8]; mean [SD] increase: 5.8 [12.8], 95% CI: 3.2-8.4; P = .003) and 11% at Month 9 (63.5 [10.7] vs 71.3 [12.2]; mean [SD] increase: 7.8 [11.0], 95% CI: 4.3-11.2; P = .003). At Month 6, common coaching lessons and respective action plans focused on progressive muscle relaxation, sleep, hydration, nutrition, general disease education, and stress management. The exit survey showed that the majority of the participants who completed the program had a meaningful and sustained improvement in their overall health and reported a high level of satisfaction with the program. The cost analysis revealed that on average participants gained 10.8 (95% CI: 9.3-12.3) working days/year that were previously lost due to migraine, resulting in a positive return on investment (ROI) of 490% (95% CI: 410%-570%), indicating a higher magnitude of savings that could be achieved by the implementation of such program. In addition to ROI and work productivity gained, participants also gained on average 13.6 (95% CI: 9.9-17.3) migraine-free days/year for their private and social life.

CONCLUSION

The employer-sponsored disease management program provided a better understanding of migraine, promoted methods and approaches to improve management by combining medical and lifestyle options leading to significant improvements in migraine symptoms that sustained beyond the intervention, supporting prolonged effectiveness of such programs. The program also provided a high ROI to the employer, supporting that the systematic inclusion of such programs into corporate well-being initiatives can be of significant benefit not only to the impacted individuals but to the employers as well.

Challenges of diabetes care management in developing countries with a high incidence of COVID-19: A brief report

BACKGROUND AND AIMS

Diabetes mellitus (DM) is one of the most critical risk factors for complications and death in COVID-19 patients. The present study aims to highlight challenges in the management of diabetic patients during the COVID-19 outbreak in developing countries.

METHODS

We reviewed the literature to obtain information about diabetic care during the Covid-19 crisis. We also seek opinions of clinicians working in undeveloped countries.

RESULTS

Current challenges faced by clinicians in the management of diabetic patients in developing countries are as follows: lack of preventive measures, inadequate number of visits, loss of the traditional method of communication with the patient, shortage of medications, impaired routine diabetic care, and absence of telehealth services.

CONCLUSIONS

Developing countries are faced with many challenges in diabetes management due to a lack of resources.

Work Group Report: COVID-19: Unmasking Telemedicine

Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.

The impact of telemental health use on healthcare costs among commercially insured adults with mental health conditions

OBJECTIVE

To determine the impact of telemental health (TMH) use on total healthcare costs and mental health (MH)-related costs paid by a third party among adults with mental health conditions (MHC).

METHOD

This study employed a pre-post design with a non-equivalent control group. The cohort comprised adults with MHCs identified using diagnosis codes from de-identified claims data of the Optum Clinformatics DataMart (2010 January 01 to 2017 June 30). We identified mental health (MH) service users and TMH users (N = 348) based on procedure codes. Non-users (N = 238,595) were defined as those who only used in-person MH services. A Difference-in-Differences (DID) analysis was performed within a multivariable two-part model (TPM) framework to examine the impact of TMH use on adjusted standardized costs (2018 US $) of all healthcare services and MH services. Patient-level and state-level factors were adjusted in TPM.

RESULTS

TMH use was associated with significantly higher MH-related costs [Marginal effect = $461.3, 95% confidence interval: $142.4-$780.2] and an excess of $370 increase in MH-related costs at follow-up as compared to baseline. However, TMH use was not associated with an increase in total third-party healthcare costs nor with changes in total costs from baseline to follow-up.

CONCLUSIONS

Despite having a higher likelihood of MH services use and MH-related costs, TMH users did not have higher total costs as compared to adults using only in-person MH services. Our findings suggest that TMH can increase access to MH care without increasing total healthcare costs among adults with MHC. Future studies exploring whether TMH use can lead to cost-savings over a longer period are warranted.

Mobile technologies to support healthcare provider to healthcare provider communication and management of care

BACKGROUND

The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes.

OBJECTIVES

To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts.

SELECTION CRITERIA

Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); - probably reduce participants' length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants' health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs.

AUTHORS' CONCLUSIONS

Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.

COVID-19 Pandemic and Beyond: Considerations and Costs of Telehealth Exercise Programs for Older Adults With Functional Impairments Living at Home-Lessons Learned From a Pilot Case Study

OBJECTIVE

The purpose of this study was to describe the process and cost of delivering a physical therapist-guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline.

METHODS

Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant.

RESULTS

A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the "value proposition" of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved.

CONCLUSIONS

The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a "blue print" for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine.

IMPACT

As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.

mHealth Apps: Disruptive Innovation, Regulation, and Trust-A Need for Balance

mHealth, the use of mobile and wireless technologies in healthcare, and mHealth apps, a subgroup of mHealth, are expected to result in more person-focussed healthcare. These technologies are predicted to make patients more motivated in their own healthcare, reducing the need for intensive medical intervention. Thus, mHealth app technology might lead to a redesign of existing healthcare architecture making the system more efficient, sustainable, and less expensive. As a disruptive innovation, it might destabilise the existing healthcare organisation through a changed role for healthcare professionals with patients accessing care remotely or online. This account coincides with the broader narrative of National Health Service policy-makers, which focusses on personalised healthcare and greater patient responsibility with the potential for significant cost reductions. The article proposes that while the concept of mHealth apps as a disruptive technology and the narrative of personalisation and responsibilisation might support a transformation of the healthcare system and a reduction of costs, both are dependent on patient trust in the safety and security of the new technology. Forcing trust in this field may only be achieved with the application of traditional and other regulatory mechanisms and with this comes the risk of reducing the effect of the technology's disruptive potential.

Applicability of the five case model to African eHealth investment decisions

BACKGROUND

eHealth programmes in African countries face fierce competition for scarce resources. Such initiatives should not proceed without adequate appraisal of their probable impacts, thereby acknowledging their opportunity costs and the need for appraisals to promote optimal use of available resources. However, since there is no broadly accepted eHealth impact appraisal framework available to provide guidance, and local expertise is limited, African health ministries have difficulty completing such appraisals. The Five Case Model, used in several countries outside Africa, has the potential to function as a decision-making tool in African eHealth environments and serve as a key component of an eHealth impact model for Africa.

METHODS

This study identifies internationally recognised metrics and readily accessible data sources to assess the applicability of the model's five cases to African countries.

RESULTS

Ten metrics are identified that align with the Five Case Model's five cases, including nine component metrics and one summary metric that aggregates the nine. The metrics cover the eHealth environment, human capital and governance, technology development, and finance and economics. Fifty-four African countries are scored for each metric. Visualisation of the metric scores using spider charts reveals profiles of the countries' relative performance and provides an eHealth Investment Readiness Assessment Tool.

CONCLUSION

The utility of these comparisons to strengthen eHealth investment planning suggests that the five cases are applicable to African countries' eHealth investment decisions. The potential for the Five Case Model to have a role in an eHealth impact appraisal framework for Africa should be validated through field testing.