E-Health Ultrasonic Diagnostic Monitoring for Analysis of Cardiac Insufficiency and Neuronal Regulation in Patients with Sepsis in Emergency Department under Image Reconstruction Algorithm

An anisotropic diffusion filtering- (ADF-) ultrasound (ADF-U) for ultrasound reconstruction was constructed based on the ADF to explore the diagnostic application of ultrasound imaging based on electronic health (E-health) for cardiac insufficiency and neuronal regulation in patients with sepsis. The 144 patients with sepsis were divided into an experimental group (78 patients with cardiac insufficiency) and a control group (66 patients with normal cardiac function), and another 58 healthy people were included in a blank control. The ultrasound examination was performed on all patients. In addition, new ultrasound image reconstruction and diagnosis were performed based on ADF and E-health, and its reconstruction effects were compared with those of the Bilateral Filter-ultrasonic (BFU) algorithm and the Wavelet Threshold-ultrasonic (WTU) algorithm. The left and right ventricular parameters and neuropeptide levels were detected and recorded. The results show that the running time, average gradient (AG), and peak signal-to-noise ratio (SNR) (PSNR) of the ADF-U algorithm were greater than those of the Bilateral Filter-ultrasonic (BFU) and Wavelet Threshold-ultrasonic (WTU), but the mean square error (MSE) was opposite (P < 0.05); the left ventricular end-systolic volume (LVESV) and the vertical distance between the mitral valve E-point to septal separation (EPSS) in the experimental group were higher than those in the control and blank group, while the left ventricular ejection fraction (LVEF), stroke volume (SV), cardiac output (CO), and left ventricular fractional shortening (LVFS) were opposite (P < 0.05); the systolic peak velocity of right ventricular free wall tricuspid annulus (Sm) and pulmonary valve blood velocity (PVBV) in the experimental group were lower than those of the control group and blank group (P < 0.05); the messenger ribonucleic acid (mRNA) of Proopiomelanocortin (POMC) and Cocain and amphetamine-regulated transcript (CART) was higher than the mRNA IN control group and blank group (P < 0.05). In short, the ADF-U algorithm proposed in this study improved the resolution, SNR, and reconstruction efficiency of E-health ultrasound images and provided an effective reference value for the diagnosis of cardiac insufficiency and neuronal adjustment analysis in patients with sepsis in the emergency department.

Socioeconomic and Demographic Disparities in the Use of Telemedicine for Ophthalmic Care during the COVID-19 Pandemic

PURPOSE

To identify disparities in the use of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

A cross-sectional study of completed clinical encounters in an academic ophthalmology center from March 2020 through August 2020.

PARTICIPANTS

A total of 5023 patients comprising 8116 ophthalmic clinical encounters.

METHODS

Medical charts were abstracted for demographic information. We identified zip code-level socioeconomic characteristics, which were drawn from the 2019 American Community Survey 5-year estimates.

MAIN OUTCOME MEASURES

The completion of a synchronous video encounter, the completion of a telephone (audio-only) encounter in the absence of any video encounters, or the completion of in-person encounters only.

RESULTS

During the study period, 8116 total clinical encounters were completed for 5023 unique patients. Of these patients, 446 (8.9%) participated in a video encounter, 642 (12.8%) completed a telephone encounter, and 3935 (78.3%) attended clinical appointments in person only. In adjusted analysis, patients who were Black (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.80; P < 0.001) or Hispanic/Latino (OR, 0.65; 95% CI, 0.49-0.85; P = 0.002) were significantly less likely to complete a video or telephone appointment. Older patients (OR, 0.99; 95% CI, 0.98-0.99; P < 0.001), patients whose primary language was not English (OR, 0.49; 95% CI, 0.28-0.82; P = 0.01), Black patients (OR, 0.45; 95% CI, 0.32-0.62; P < 0.001), and Hispanic/Latino patients (OR, 0.56; 95% CI, 0.37-0.83; P = 0.005) were significantly less likely to complete a video encounter. Finally, among patients completing any type of telemedicine encounter, older age, (OR, 1.02; 95% CI, 1.01-1.03; P < 0.001), Medicare insurance (OR, 1.55; 95% CI, 1.11-2.17; P = 0.01), and Black race (OR, 1.97; 95% CI, 1.33-2.94; P < 0.001) were associated with using only phone visits.

CONCLUSIONS

Ethnic/racial minorities, older patients, and non-English-speaking individuals were significantly less likely to complete a video telehealth encounter. With the expansion of telemedicine and the need to reduce the disparate impact of COVID-19 on minorities, it will be increasingly important to identify barriers to telehealth use and opportunities to improve access.

Disparities in Eye Care Utilization During the COVID-19 Pandemic

PURPOSE

To assess the relationship between telemedicine utilization and sociodemographic factors among patients seeking eye care.

DESIGN

Comparative utilization analysis.

METHODS

We reviewed the eye care utilization patterns of a stratified random sample of 1720 patients who were seen at the University of Michigan Kellogg Eye Center during the height of the COVID-19 pandemic (April 30 to May 25, 2020) and their odds of having a video, phone, or in-person visit compared with having a deferred visit. Associations between independent variables and visit type were determined using a multinomial logistic regression model.

RESULTS

Older patients had lower odds of having a video visit (P = .007) and higher odds of having an in-person visit (P = .023) compared with being deferred, and in the nonretina clinic sample, older patients still had lower odds of a video visit (P = .02). Non-White patients had lower odds of having an in-person visit (P < .02) in the overall sample compared with being deferred, with a similar trend seen in the retina clinic. The mean neighborhood median household income was $76,200 (±$33,500) and varied significantly (P < .0001) by race with Blacks having the lowest estimated mean income.

CONCLUSION

Disparities exist in how patients accessed eye care during the COVID-19 pandemic with older patients-those for whom COVID-19 posed a higher risk of mortality-being more likely to be seen for in-person care. In our affluent participant sample, there was a trend toward non-White patients being less likely to access care. Reimbursing telemedicine solely through broadband internet connection may further exacerbate disparities in eye care.

The Impacts of the COVID-19 Pandemic on the Medical Expenditure Panel Survey

The COVID-19 pandemic caused substantial disruptions in the field operations of all 3 major components of the Medical Expenditure Panel Survey (MEPS). The MEPS is widely used to study how policy changes and major shocks, such as the COVID-19 pandemic, affect insurance coverage, access, and preventive and other health care utilization and how these relate to population health. We describe how the MEPS program successfully responded to these challenges by reengineering field operations, including survey modes, to complete data collection and maintain data release schedules. The impact of the pandemic on response rates varied considerably across the MEPS. Investigations to date show little effect on the quality of data collected. However, lower response rates may reduce the statistical precision of some estimates. We also describe several enhancements made to the MEPS that will allow researchers to better understand the impact of the pandemic on US residents, employers, and the US health care system. (Am J Public Health. 2021;111(12):2157-2166. https://doi.org/10.2105/AJPH.2021.306534).

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States

PURPOSE

We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features.

MATERIALS AND METHODS

We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021.

RESULTS

We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively).

CONCLUSIONS

This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

Changes to telehealth practices in primary care in New Brunswick (Canada): A comparative study pre and during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, telehealth technologies were used in the primary health care setting in New Brunswick as a means to continue providing care to patients while following public health guidelines. This study aimed to measure these changes and examine if they improved timely access to primary care. A secondary goal was to identify which telehealth technologies were deemed sustainable by primary care providers.

METHODS

This was a comparative study on the use of telehealth technology before and during the COVID-19 pandemic. Between April 2020 and November 2020, 114 active primary care providers (family physicians or nurse practitioners) responded to the online survey.

RESULTS

The findings illustrated an increase in the use of telehealth technologies. The use of phone consultations increased by 122%, from 43.9% pre-pandemic to 97.6% during the pandemic (p < 0.001). The use of virtual consultation (19.3% pre-pandemic vs. 41.2% during the pandemic, p < 0.001), emails and texts also increased during the pandemic. Whereas the more structural organizational tools (electronic medical charts and reservation systems) remained stable. However, those changes did not coincide with a significant improvement to timely access to care during the pandemic. Many participants (40.1%) wanted to keep phone consultations, and 21.9% of participants wanted to keep virtual consultations as part of their long-term practice.

INTERPRETATION

The observed increase in the use of telehealth technologies may be sustainable, but it has not significantly improved timely access to primary care in New Brunswick.

Analysis of Clinician and Patient Factors and Completion of Telemedicine Appointments Using Video

IMPORTANCE

Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits.

OBJECTIVE

To assess patient and clinician factors associated with successful and with failed video visits.

DESIGN, SETTING, AND PARTICIPANTS

This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures.

RESULTS

In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors.

CONCLUSIONS AND RELEVANCE

As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

IMPORTANCE

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.

OBJECTIVE

To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.

MAIN OUTCOMES AND MEASURES

Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.

RESULTS

This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.

CONCLUSIONS AND RELEVANCE

In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Multicenter evaluation of breast cancer patients' satisfaction and experience with oncology telemedicine visits during the COVID-19 pandemic

INTRODUCTION

During the COVID-19 pandemic, teleconsultation was implemented in clinical practice to limit patient exposure to COVID-19 while monitoring their treatment and follow-up. We sought to examine the satisfaction of patients with breast cancer (BC) who underwent teleconsultations during this period.

METHODS

Eighteen centres in France and Italy invited patients with BC who had at least one teleconsultation during the first wave of the COVID-19 pandemic to participate in a web-based survey that evaluated their satisfaction (EORTC OUT-PATSAT 35 and Telemedicine Satisfaction Questionnaire [TSQ] scores) with teleconsultation.

RESULTS

Among the 1299 participants eligible for this analysis, 53% of participants were undergoing standard post-treatment follow-up while 22 and 17% were currently receiving active anticancer therapy for metastatic and localised cancers, respectively. The mean satisfaction scores were 77.4 and 73.3 for the EORTC OUT-PATSAT 35 and TSQ scores, respectively. In all, 52.6% of participants had low/no anxiety. Multivariable analysis showed that the EORTC OUT-PATSAT 35 score correlated to age, anxiety score and teleconsultation modality. The TSQ score correlated to disease status and anxiety score.

CONCLUSION

Patients with BC were satisfied with oncology teleconsultations during the COVID-19 pandemic. Teleconsultation may be an acceptable alternative follow-up modality in specific circumstances.

Changes in Care Delivery for Children With Sickle Cell Anemia During the COVID-19 Pandemic

BACKGROUND

Specialty care for children with sickle cell disease (SCD) may be disrupted during the coronavirus (COVID-19) pandemic. Our DISPLACE consortium includes 28 pediatric SCD centers.

METHODS

In May 2020, we surveyed the consortium on the impact of COVID-19 on their practice focusing on transcranial Doppler ultrasound, chronic red cell transfusions, telehealth, and COVID-19 testing.

OBSERVATION

Twenty-four DISPLACE providers completed the survey. Transcranial Doppler ultrasound screening decreased to 67% but chronic red cell transfusions remained at 96%. Most investigators (92%) used telehealth and 40% of providers had patients test positive for COVID-19.

CONCLUSION

The COVID-19 pandemic has affected routine care and necessitated changes in practice in SCD.

Attitudes and Perceptions of Multidisciplinary Cancer Care Clinicians Toward Telehealth and Secure Messages

Importance

Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic.

Objective

To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages.

Design, Setting, and Participants

Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California.

Main Outcomes and Measures

Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use.

Results

A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic.

Conclusions and Relevance

In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period.

Using a Blur Metric to Estimate Linear Motion Blur Parameters

Motion blur is a common artifact in image processing, specifically in e-health services, which is caused by the motion of a camera or scene. In linear motion cases, the blur kernel, i.e., the function that simulates the linear motion blur process, depends on the length and direction of blur, called linear motion blur parameters. The estimation of blur parameters is a vital and sensitive stage in the process of reconstructing a sharp version of a motion blurred image, i.e., image deblurring. The estimation of blur parameters can also be used in e-health services. Since medical images may be blurry, this method can be used to estimate the blur parameters and then take an action to enhance the image. In this paper, some methods are proposed for estimating the linear motion blur parameters based on the extraction of features from the given single blurred image. The motion blur direction is estimated using the Radon transform of the spectrum of the blurred image. To estimate the motion blur length, the relation between a blur metric, called NIDCT (Noise-Immune Discrete Cosine Transform-based), and the motion blur length is applied. Experiments performed in this study showed that the NIDCT blur metric and the blur length have a monotonic relation. Indeed, an increase in blur length leads to increase in the blurriness value estimated via the NIDCT blur metric. This relation is applied to estimate the motion blur. The efficiency of the proposed method is demonstrated by performing some quantitative and qualitative experiments.

Primary care bonus payments and patient-reported access in urban Ontario: a cross-sectional study

BACKGROUND

Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings.

METHODS

We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome.

RESULTS

We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes.

INTERPRETATION

Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.

Survey of COVID-19 impact on pediatric urology services

INTRODUCTION

To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning.

MATERIALS AND METHODS

A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020.

RESULTS

The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable.

CONCLUSIONS

Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.

Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience

PURPOSE

To assess the initial utilization, safety, and patient experience with tele-ophthalmology during the COVID-19 pandemic.

DESIGN

Cross-sectional study.

METHODS

We conducted a telephone survey and interview of a random sample of patients who received different modalities of care (in-person, telephone, videocall, or visits deferred) during Michigan's shelter-in-place order beginning March 23, 2020. The survey assessed patient safety, patient satisfaction with care, perceptions of telehealth-based eye care, and worry about eyesight. Data were analyzed via frequency measures (eg, means and standard deviations), χ2 tests, ANOVA, and paired t tests. Interviews were analyzed using grounded theory.

RESULTS

A total of 3,274 patients were called and 1,720 (53%) agreed to participate. In-person participants were significantly older than telephone (P = .002) and videocall visit (P = .001) participants. Significantly more white participants had in-person visits than minority participants (P = .002). In-person visit participants worried about their eyesight more (2.7, standard deviation [SD] = 1.2) than those who had telephone (2.5, SD = 1.3), videocall (2.4, SD = 1.1), or deferred visits (2.4, SD = 1.2) (P = .004). Of all telephone or videocall visits, 1.5% (n = 26) resulted in an in-person visit within 1 day, 2.9% (n = 48) within 2-7 days, and 2.4% (n = 40) within 8-14 days after the virtual visit demonstrating appropriate triage to telemedicine-based care. Patients frequently cited a desire for augmenting the telephone or videocall visits with objective test data.

CONCLUSIONS

When appropriately triaged, tele-ophthalmology appears to be a safe way to reduce the volume of in-person visits to promote social distancing in the clinic. A hybrid model of eye care combining ancillary testing with a video or phone visit represents a promising model of care.

Changes in Virtual and In-Person Health Care Utilization in a Large Health System During the COVID-19 Pandemic

This cross-sectional study evaluates how the growth of virtual care has impacted health care utilization in an integrated delivery network.

Assessment of Changes in US Veterans Health Administration Care Delivery Methods During the COVID-19 Pandemic

This cross-sectional study assesses changes in health care delivery methods, including all forms of care either purchased or provided by the Veterans Health Administration (VHA), for VHA enrollees in response to the COVID-19 pandemic.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis

BACKGROUND

The prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in access to good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable.

METHODS

We conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants' experiences and views regarding telemental health during the pandemic were identified and extracted. Data collection and analysis used a participatory, coproduction approach where researchers with relevant lived experience, contributed to all stages of data collection, analysis and interpretation of findings alongside clinical and academic researchers.

FINDINGS

The experiences and preferences regarding telemental health care of the forty-four participants were dynamic and varied across time and settings, as well as between individuals. Participants' preferences were shaped by reasons for contacting services, their relationship with care providers, and both parties' access to technology and their individual preferences. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important challenges related to safety and privacy in online settings, and gave examples of good remote care strategies they had experienced, including services scheduling regular phone calls and developing guidelines about how to access remote care tools.

DISCUSSION

Participants in our study have highlighted advantages of telemental health care, as well as significant limitations that risk hindering mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and of supporting staff in making effective and collaborative use of relevant technologies.

Influential Usage of Big Data and Artificial Intelligence in Healthcare

Artificial intelligence (AI) is making computer systems capable of executing human brain tasks in many fields in all aspects of daily life. The enhancement in information and communications technology (ICT) has indisputably improved the quality of people's lives around the globe. Especially, ICT has led to a very needy and tremendous improvement in the health sector which is commonly known as electronic health (eHealth) and medical health (mHealth). Deep machine learning and AI approaches are commonly presented in many applications using big data, which consists of all relevant data about the medical health and diseases which a model can access at the time of execution or diagnosis of diseases. For example, cardiovascular imaging has now accurate imaging combined with big data from the eHealth record and pathology to better characterize the disease and personalized therapy. In clinical work and imaging, cancer care is getting improved by knowing the tumor biology and helping in the implementation of precision medicine. The Markov model is used to extract new approaches for leveraging cancer. In this paper, we have reviewed existing research relevant to eHealth and mHealth where various models are discussed which uses big data for the diagnosis and healthcare system. This paper summarizes the recent promising applications of AI and big data in medical health and electronic health, which have potentially added value to diagnosis and patient care.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks

IMPORTANCE

It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed.

OBJECTIVE

To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified.

EXPOSURES

For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics.

MAIN OUTCOMES AND MEASURES

Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients.

RESULTS

Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients.

CONCLUSIONS AND RELEVANCE

This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

Patient Adherence to Hemoglobin A1c Testing Recommendations in Telemedicine and In-Office Cohorts During COVID-19

This cohort study assesses patient adherence to diabetes screening using hemoglobin A_1c level at in-person vs telemedicine encounters during the COVID-19 pandemic in the US.

Disparities in Telemedicine Use for Subspecialty Diabetes Care During COVID-19 Shelter-In-Place Orders

BACKGROUND

During the COVID-19 pandemic, telemedicine use rapidly and dramatically increased for management of diabetes mellitus. It is unknown whether access to telemedicine care has been equitable during this time. This study aimed to identify patient-level factors associated with adoption of telemedicine for subspecialty diabetes care during the pandemic.

METHODS

We conducted an explanatory sequential mixed-methods study using data from a single academic medical center. We used multivariate logistic regression to explore associations between telemedicine use and demographic factors for patients receiving subspecialty diabetes care between March 19 and June 30, 2020. We then surveyed a sample of patients who received in-person care to understand why these patients did not use telemedicine.

RESULTS

Among 1292 patients who received subspecialty diabetes care during the study period, those over age 65 were less likely to use telemedicine (OR: 0.34, 95% CI: 0.22-0.52, P < .001), as were patients with a primary language other than English (OR: 0.53, 95% CI: 0.31-0.91, P = .02), and patients with public insurance (OR: 0.64, 95% CI: 0.49-0.84, P = .001). Perceived quality of care and technological barriers were the most common reasons cited for choosing in-person care during the pandemic.

CONCLUSIONS

Our findings suggest that, amidst the COVID-19 pandemic, there have been disparities in telemedicine use by age, language, and insurance for patients with diabetes mellitus. We anticipate telemedicine will continue to be an important care modality for chronic conditions in the years ahead. Significant work must therefore be done to ensure that telemedicine services do not introduce or widen population health disparities.