Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

Are patients satisfied with a web-based followup after total joint arthroplasty?

BACKGROUND

A web-based followup assessment may be a feasible, cost-saving alternative of tracking patient outcomes after total joint arthroplasty. However, before implementing a web-based program, it is important to determine patient satisfaction levels with the new followup method. Satisfaction with the care received is becoming an increasingly important metric, and we do not know to what degree patients are satisfied with an approach to followup that does not involve an in-person visit with their surgeons.

QUESTIONS/PURPOSES

We determined (1) patient satisfaction and (2) patients' preferences for followup method (web-based or in-person) after total joint arthroplasty.

METHODS

We randomized patients who were at least 12 months after primary THA or TKA to complete a web-based followup or to have their appointment at the clinic. There were 410 eligible patients contacted for the study during the recruitment period. Of these, 256 agreed to participate, and a total of 229 patients completed the study (89% of those enrolled, 56% of those potentially eligible; 111 in the usual-care group, 118 in the web-based group). Their mean age was 69 years (range, 38-86 years). There was no crossover between groups. All 229 patients completed a satisfaction questionnaire at the time of their followup appointments. Patients in the web-based group also completed a satisfaction and preference questionnaire 1 year later. Only patients from the web-based group were asked to indicate preference as they had experienced the web-based and in-person followup methods. We used descriptive statistics to summarize the satisfaction questionnaires and compared results using Pearson's chi-square test.

RESULTS

Ninety-one patients (82.0%) in the usual-care group indicated that they were either extremely or very satisfied with the followup process compared with 90 patients (75.6%) who were in the web-based group (p < 0.01; odds ratio [OR] = 3.95; 95% CI, 1.79-8.76). Similarly, patients in the usual care group were more satisfied with the care they received from their surgeon, compared with patients in the web-based group (92.8% versus 73.9%; p < 0.01, OR = 1.37; 95% CI, 0.73-2.57). Forty-four percent of patients preferred the web-based method, 36% preferred the usual method, and 16% had no preference (p = 0.01).

CONCLUSIONS

Our results show moderate to high satisfaction levels with a web-based followup assessment. Patients who completed the usual method of in-person followup assessment reported greater satisfaction; however, the difference was small and may not outweigh the additional cost and time-saving benefits of the web-based followup method.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

An exploration of the follow-up up needs of patients with inflammatory bowel disease

BACKGROUND AND AIMS

The rising incidence of inflammatory bowel disease (IBD) in adults and children has implications for the lifelong burden of disease and the provision of specialist services. Patients with IBD should have access to specialist care which is delivered according to their values and needs. Few studies have examined patients' views of follow-up care. The aim of this qualitative study was to explore patients' needs, preferences and views of follow-up care.

METHODS

IBD patients were selected from a gastroenterology clinic in a UK Hospital and invited to participate in interviews which focused on needs, preferences and role of follow-up, their experience of follow-up, service delivery, and other models of follow-up care.

RESULTS

24 patients were recruited, 18 patients had Crohn's Disease, and 6 ulcerative colitis. Median age was 48.5 years (range was 27-72 years) and median disease duration 11.5 years (range 2-40 years). Four main themes emerged: (1) experiences of current follow-up care; (2) attitudes to new models of care, including self-management, role of general practitioner, patient-initiated consultations and 'virtual' follow-up; (3) the personal value of follow-up care; and (4) the 'ideal' consultation.

CONCLUSION

The main finding was that patients prefer a more flexible follow-up care system. 'Virtual' care as an adjunct to patient-initiated consultations and self-management, was identified as optimal approaches to meet the patients' needs of follow-up care. New models of follow-up care could improve the patients' experience of care, offer potential cost savings with reduction in face-to-face consultations and allow targeted care to those who need it.

Surgical telementoring in knowledge translation--clinical outcomes and educational benefits: a comprehensive review

BACKGROUND

Surgical telementoring has been reported for decades. However, there exists limited evidence of clinical outcome and educational benefits.

OBJECTIVE

To perform a comprehensive review of surgical telementoring surveys published in the past 2 decades.

RESULTS

Of 624 primary identified articles, 34 articles were reviewed. A total of 433 surgical procedures were performed by 180 surgeons. Most common telementored procedures were laparoscopic cholecystectomy (57 cases, 13%), endovascular treatment of aortic aneurysm (48 cases, 11%), laparoscopic colectomy (32 cases, 7%), and nefrectomies (41 cases, 9%). In all, 167 (38%) cases had a laparoscopic approach, and 8 cases (5%) were converted to open surgery. Overall, 20 complications (5%) were reported (liver bleeding, trocar port bleeding, bile collection, postoperative ileus, wound infection, serosa tears, iliac artery rupture, conversion open surgery). Eight surveys (23%) have structured assessment of educational outcomes. Telementoring was combined with simulators (n = 2) and robotics (n = 3). Twelve surveys (35%) were intercontinental. Technology satisfaction was high among 83% of surgeons.

CONCLUSION

Few surveys have a structured assessment of educational outcome. Telementoring has improved impact on surgical education. Reported complication rate was 5%.

An electronic clinic for arthroplasty follow-up: a pilot study

BACKGROUND

Most outpatient orthopedic follow-up visits for patients who had total joint arthroplasty are routine among those with well-functioning implants. The technology and resources now exist to enable patient assessment without requiring attendance in hospital. We tested an electronic clinic for routine follow-up in a small cohort of arthroplasty patients.

METHODS

We randomly assigned primary arthroplasty patients scheduled for routine annual outpatient review into 2 groups: group A completed a Web-based assessment 4 weeks after the clinical assessment, whereas group B completed the Web-based assessment first. Standard clinical questionnaires were included. We also collected radiographic data and information on assessment duration and cost.

RESULTS

Forty patients participated in the study. The average age of participants was 58 years. There were 12 men and 8 women in each of the 2 groups. The average total time spent by patients on an outpatient visit was 115 minutes, compared with 52 minutes for the electronic assessment. Participants reported the electronic assessment to be more convenient and less costly.

CONCLUSION

This pilot study supports the practical use of an electronic clinic for the follow-up of arthroplasty patients. Further studies examining the complex interaction of factors involved in patient clinics are needed.

Sleep telemedicine: patient satisfaction and treatment adherence

OBJECTIVE

Obstructive sleep apnea is common, but access to diagnosis remains limited. Telemedicine may allow greater access to care; however, its effect on patient satisfaction and treatment adherence is unknown. This study compares patient satisfaction and continuous positive airway pressure (CPAP) adherence of patients seen by videoconference with those seen in person.

MATERIALS AND METHODS

New patients seen via video or in person at a sleep center completed a survey, with three questions pertaining to satisfaction with the provider. Questions were scored 1-5; the sum was the patient satisfaction score. CPAP adherence was retrospectively analyzed in patients who met the physician via video or in person. Percentage of nights CPAP was used for ≥4 h and average minutes of CPAP use per night over 2 consecutive weeks were compared.

RESULTS

A Mann-Whitney test compared patient satisfaction of the 90 subjects (of whom, 56 met physician in person and 34 via video). Mean scores (in person, 14.82; video, 14.91; p=0.851) did not differ between groups. Mann-Whitney tests compared CPAP adherence in the 172 subjects (of whom, 111 met physician in person and 61 via video). Mean percentage of nights CPAP was used ≥4 h (in person, 71%; video, 65%; p=0.198) and the average minutes per night of CPAP use (in person, 340.55; video, 305.31; p=0.153) did not differ between groups.

CONCLUSIONS

The findings indicate that patients were equally satisfied with their provider and adherent to CPAP treatment whether they were seen in person or via video. Videoconferencing may improve access to patient care without reducing patient satisfaction or treatment adherence.

Telemedicine: the role of specialist second opinion for GPs in the care of hypertensive patients

RATIONALE

To evaluate the feasibility of a second-opinion consultation in supporting general practitioners (GPs) during the daily diagnosis and therapeutic management of patients with essential hypertension.

METHODS

Italian GPs were encouraged to follow-up their patients by the use of the Telemedicine Service. All known hypertensive patients with signs and symptoms (teleconsultation for symptoms) and all asymptomatic patients (teleconsultation for clinical control) undergoing a visit by their GPs were enrolled. During the first visit, the GP performed electrocardiography (ECG), measured blood pressure and required cardiological teleconsultation.

RESULTS

399 GPs examined 1719 consecutive patients (mean age 73±13 years, 38% male). During teleconsultation for a routine control, GPs identified 36% of new episodes of atrial fibrillation in the absence of any symptom and about 70% of patients with uncontrolled blood pressure. In about 50% of the cases, 10 min of teleconsultation helped GP to quicken the solution of the clinical problems, reducing time and number of specialist's visit. In 8% of cases, an emergency department admission was suggested.

CONCLUSIONS

Telemedicine applied to hypertensive patients at high risk of cardiovascular problems offers to GPs an easy-to-use tool to control blood pressure by improving connection with second-opinion specialist consultations.

The physical examination in telecardiology and televascular consultations: a study using conversation analysis

OBJECTIVE

This paper describes communication in the physical examination phases of telemedicine consultations.

METHODS

Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.

RESULTS

Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.

CONCLUSION

Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses' examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.

PRACTICE IMPLICATIONS

The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.

Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness

Background

Nowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas.

Methods

General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires.

Results

There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account.

Conclusions

Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services.

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons

Background

Since the 1960s, there has been substantial development in the uses of video-conferencing (VC) among medical personnel, including surgeons who have adopted the technology.

Methods

A report on our own experience with VC was combined with a comprehensive PubMed search with the key words telepresence, video-conferencing, video-teleconferencing, telementoring and surgery, trauma, follow-up, education, and multidisciplinary teams. A search through two peer-reviewed telemedicine journals—Journal of Telemedicine and Telecare and Telemedicine and e-Health Journal—and references of all included papers and identified additional reports was conducted.

Results

A total of 517 articles were identified with 51 relevant manuscripts, which included the key phrases. VC is widely used among surgeons for telementoring surgical procedures and in trauma and emergency medicine. Furthermore, VC is widely used by multidisciplinary teams and for the follow-up of patients after surgery.

Conclusions

VC is a common clinical tool for surgeons and provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment despite long distances, especially in rural areas.

An evaluation of the appropriateness of advice and healthcare contacts made following calls to NHS Direct Wales

Background

An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here.

Methods

Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received.

Results

Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs.

More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%).

Conclusion

Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

A comparative cost analysis of digital fundus imaging and direct fundus examination for assessment of diabetic retinopathy

The objective of this study was to compare the cost between two procedures for fundus examination in patients with diabetes. In our setting, two alternatives for fundus examination are available for patients with diabetes. In the first alternative, a digital image is taken with a nonmydriatic fundus camera when the patient is at the endocrinology consultation, and the image is then examined by an ophthalmologist. In the second alternative, a direct fundus examination is made by an ophthalmologist. We calculated the costs of both procedures from both Public Healthcare System (PHS) and patient perspectives using the official scales to compute personnel, consumables, capital cost of equipment, travel expenses, and time loss of the patient caused by attending the consultation. The first alternative (digital fundus image) required 2.69, 0.03, and 1.62 Euros per patient for personnel, consumables, and capital cost of the equipment, respectively. A direct fundus examination was needed in 31% of patients that had an additional cost of 0.97 Euros per patient for the PHS plus 14.97 Euros per patient because of travel cost and loss of income. The second alternative (direct fundus examination) required 2.69, 0.11, and 0.33 Euros per patient for personnel, consumables, and capital cost, respectively. All patients in this second alternative had to attend a consultation that implied travel and loss of income costs. Attending a consultation represented a cost of 48.29 Euros per patient. From the PHS perspective, direct fundus examination is less costly than using digital fundus images. The higher cost of the digital fundus option is a consequence of the higher capital costs required by the equipment needed to obtain the digital image. However, from a global perspective, the digital image alternative is more convenient because the travel cost and loss of income of the patient are lower.

Teleconsultation – collaborative work and opportunities for learning across organizational boundaries

Over a period of five months we observed teleconsultations between general practitioners (GPs) in community care and specialists in hospitals in two Norwegian health regions (A and B). In total, 47 teleconsultations between GPs and specialists were recorded. In region A, teleconsultations were organized when needed to discuss specific medical problems. In region B, teleconsultations took place during the specialists' daily morning meeting. The teleconsultations lasted for 5–40 min. There were three categories of talk. In the first two there was information exchange for patient updates and practical organization of the service. The third category, consultation, was the communicative process in which the GP and the specialist engaged in collaborative work, primarily discussing medical problems related to decision-making in patient care. Regular use of teleconsultation opens access to different repertoires of knowledge and experience, and brings knowledge to the point of patient care and medical decision-making.

Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system

OBJECTIVE

To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM).

PARTICIPANTS AND METHODS

As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective).

RESULTS

During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%; 95% confidence interval, -19% to 17%). The intervention group incurred lower costs (P=.02) but not in diabetes-related costs.

CONCLUSION

Specialty telemedicine did not significantly enhance the value of CCM in primary care.

Flexible parametric models for random-effects distributions

It is commonly assumed that random effects in hierarchical models follow a normal distribution. This can be extremely restrictive in practice. We explore the use of more flexible alternatives for this assumption, namely the t distribution, and skew extensions to the normal and t distributions, implemented using Markov Chain Monte Carlo methods. Models are compared in terms of parameter estimates, deviance information criteria, and predictive distributions. These methods are applied to examples in meta-analysis and health-professional variation, where the distribution of the random effects is of direct interest. The results highlight the importance of allowing for potential skewing and heavy tails in random-effects distributions, especially when estimating a predictive distribution. We describe the extension of these random-effects models to the bivariate case, with application to a meta-analysis examining the relationship between treatment effect and baseline response. We conclude that inferences regarding the random effects can crucially depend on the assumptions made and recommend using a distribution, such as those suggested here, which is more flexible than the normal.

Measuring patient assessments of the quality of outpatient care: a systematic review

RATIONALE, AIMS AND OBJECTIVES

The aim of the study was to answer three questions: first, what methods have been used to measure patient assessments of the quality of care? Second, how do outpatients rate their care? And third, what needs to be taken into account in measuring patient assessments of the quality of care?

METHODS

Systematic review of the literature. Electronic searches were conducted on Medline, CINAHL and the Cochrane Database of Systematic Reviews. To be included, articles were to deal with patients' assessments of health care in ambulatory units for somatic adult patients. They were to have been published between January 2000 and May 2005, written in English, Swedish or Finnish with an English abstract, and the research was to have been conducted in Europe. The search terms used were: ambulatory care, ambulatory care facilities, outpatient, outpatients, patient satisfaction and quality of health care. The articles were screened by two independent reviewers in three phases.

RESULTS

Thirty-five articles were included. The quality of care was measured using both quantitative and qualitative methods. Only a few studies relied on the single criterion of patient satisfaction for quality measurements. It is easy to identify common sources of dissatisfaction in different studies. Sources of satisfaction are more closely dependent on the target population, the context and research design.

CONCLUSION

Patient satisfaction is widely used as one indicator among others in assessing the quality of outpatient care. However, there is no single, universally accepted method for measuring this.

TELEMAM: a cluster randomised trial to assess the use of telemedicine in multi-disciplinary breast cancer decision making

AIM

The TELEMAM trial aimed to assess the clinical effectiveness and costs of telemedicine in conducting breast cancer multi-disciplinary meetings (MDTs).

METHODS

Over 12 months 473 MDT patient discussions in two district general hospitals (DGHs) were cluster randomised (2:1) to the intervention of telemedicine linkage to breast specialists in a cancer centre or to the control group of 'in-person' meetings. Primary endpoints were clinical effectiveness and costs. Economic analysis was based on a cost-minimisation approach.

RESULTS

Levels of agreement of MDT members on a scale from 1 to 5 were high and similar in both the telemedicine and standard meetings for decision sharing (4.04 versus 4.17), consensus (4.06 versus 4.20) and confidence in the decision (4.16 versus 4.07). The threshold at which the telemedicine meetings became cheaper than standard MDTs was approximately 40 meetings per year.

CONCLUSION

Telemedicine delivered breast cancer multi-disciplinary meetings have similar clinical effectiveness to standard 'in-person' meetings.

Diagnosis, access and outcomes: Update of a systematic review of telemedicine services

Telemedicine services are being increasingly used. Although insurers and other payers are covering some services in the USA, the rationale for these coverage decisions is not always evidence-based. We reviewed the literature for telemedicine services that substitute for face-to-face medical diagnosis and treatment. We focused on three types of telemedicine services: store-and-forward, home-based and office/hospital-based services. Studies were included if they were relevant to at least one of the three study areas, addressed at least one key question and contained reported results. We excluded articles that did not study a service requiring face-to-face encounters (i.e. teleradiology was excluded). Our search initially identified 4083 citations. After review, 597 were judged to be potentially relevant at the title/abstract level. Following a full-text review, 106 studies were included. Store-and-forward services have been studied in many specialties, the most common being dermatology, wound care and ophthalmology. The evidence for their efficacy is mixed. Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. Studies of office/hospital-based telemedicine suggest that telemedicine is most effective for verbal interactions, e.g. videoconferencing for diagnosis and treatment in specialties like neurology and psychiatry. There are still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence. Further well-designed research is necessary to understand how best to deploy telemedicine services in health care.

Solving the disjuncture between research and practice: telehealth trends in the 21st century

Despite the great promise that telehealth holds for improving cost, quality and access, there is currently a disjunction between what we know about telehealth and system growth and performance. To better understand the relationship between these two facets of telehealth development, this paper examines trends in telehealth, both as an intellectual endeavor and as a practical means of providing health services. Although there are promising avenues for government intervention in the way of coordination, funding, and regulatory practice, lack of knowledge regarding what works and what does not work has served as a major impediment to further progress in this area. In the absence of solid empirical evidence, key decision makers entertain doubts about telehealth's effectiveness, which, in turn, limits public leadership, private investment, and the long-term integration of telehealth into the health and technological mainstream. Solving the disjuncture between research and practice will require additional clinical trials and evaluation studies that examine the efficacy of various technologies, both relative to each other and to conventional in person medical encounters. At the same time, it will require more even distribution of research across applications, service locations, regions, and nations. But the generation of additional high-quality empirical data on process, benefits, costs, and effects is only the beginning. That data must in turn be used to effectuate change. This will require researchers to take a more proactive stance in promoting use of their findings, both instrumentally, to adjust, modify or improve particular programs or policies, and conceptually, to influence how key stakeholders think about telehealth more generally.

The use of random effects models to allow for clustering in individually randomized trials

BACKGROUND

We describe different forms of clustering that may occur in individually randomized trials, where the observed outcomes for different individuals cannot be regarded as independent. We propose random effects models to allow for such clustering, across a range of contexts and trial designs, and investigate their effect on estimation and interpretation of the treatment effect.

METHODS

We apply our proposed models to two individually randomized trials with potential for clustering, a trial of teleconsultation in hospital referral (the main outcome being offer of a further hospital appointment) and a trial of exercise therapy delivered by physiotherapists for low back pain (the outcome being a back pain score). Extensions to the methods include the possibility of explaining heterogeneity between clusters using cluster level characteristics and the potential dilution of cluster effects due to noncompliance.

RESULTS

In the teleconsultation trial, the odds ratio was significant (1.52, 95% CI 1.27 to 1.82) when clustering was ignored, but smaller and nonsignificant (1.36, 95% CI 0.85 to 2.13) when clustering by hospital consultant was taken into account. The 95% range of estimated treatment effects across consultants was from 0.21 to 8.76. This variability was only partially explained by the specialty of the consultant. In the back pain trial, although there was an overall benefit of exercise (change of - 0.51 points on the back pain score) and little evidence of clustering, the estimated treatment effects for different physiotherapists ranged from -1.26 to +0.26 points.

CONCLUSIONS

Clustering is an important issue in many individually randomized trials. Ignoring it can lead to underestimates of the uncertainty and too extreme P-values. Even when there is little apparent heterogeneity across clusters, it can still have a large impact on the estimation and interpretation of the treatment effect.

Specialist outreach to isolated and disadvantaged communities: a population-based study

BACKGROUND

Visiting-specialist clinics (specialist outreach) have the potential to overcome some of the substantial access barriers faced by disadvantaged rural, remote, and Indigenous communities, but the effectiveness of outreach clinics has not been assessed outside urban and non-disadvantaged settings. We aimed to assess the effects of outreach clinics on access, referral patterns, and care outcomes in remote communities in Australia.

METHODS

We undertook a population-based observational study of regular surgical, ophthalmological, gynaecological, and ear, nose, and throat outreach visits, compared with hospital clinics alone, on access, referral practices, and outcomes for the populations of three remote Indigenous communities in northern Australia for 11 years. We assessed all new non-emergency potential specialist surgical cases who presented initially between Jan 1, 1990, and Jan 1, 2001. The effects of outreach clinics on the proportion of patients referred, the time from referral to initial specialist consultation, and the rates of community-based and hospital-based procedures were analysed using logic regression and Cox proportional hazard models.

FINDINGS

2339 new surgical problems presented in 2368 people between 1990 and 2001. Outreach improved the rate of referral completion (adjusted hazard ratio 1.41, 95% CI 1.07-1.86) and the risk of timely completion according to the urgency of referral (adjusted relative risk 1.30, 1.05-1.53). Outreach had no significant effect on initiation of elective referrals, but there were 156 opportunistic presentations on outreach clinic days. Specialist investigations and procedures in community clinics removed the need for many patients to travel to hospital, and outreach consultations were associated with a reduced rate of procedures that needed hospital admission (adjusted hazard ratio 0.67, 0.43-1.03).

INTERPRETATION

Specialist outreach visits to remote disadvantaged Indigenous communities in Australia improve access to specialist consultations and procedures without increasing elective referrals or demands for hospital inpatient services.

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.

Patients' perceptions of joint teleconsultations: a qualitative evaluation

OBJECTIVE

To determine patient perceptions of joint teleconsultations (JTC), with particular reference to reasons underlying, and factors contributing to, patient satisfaction and dissatisfaction with this mode of health delivery.

BACKGROUND

Telemedicine has been welcomed as one way of improving health-care delivery, by improving patient access to secondary care and specialist services hence widening patient choice, particularly for patients outside major conurbations. However, a recent systematic review found currently available data on patient satisfaction with telemedicine to be methodologically flawed. Qualitative evaluations offer the opportunity to elucidate the details of patient satisfaction with this mode of health-care delivery.

DESIGN

Qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

Purposive sample of 28 participants of a major randomized controlled trial (Virtual Outreach study) of JTC conducted in one urban and one rural area in Britain.

INTERVENTION

Joint teleconferenced consultations with the patient, patient's general practitioner (GP), and a hospital specialist. The patient and GP were sited in the local practice, while the hospital specialist was in the hospital outpatient department, and the two parties were connected by an ISDN2 link and video-conferencing software.

MAIN OUTCOME MEASURES

Patient experiences of JTC, with particular reference to reasons underlying, and factors contributing to, overall satisfaction or dissatisfaction.

RESULTS

Two major themes were identified: customer care and doctor-patient interaction. Patients appreciated the customer care aspects of JTC, particularly the enhanced convenience, reduced costs and improved punctuality associated with JTC. However, there were divergent views about the doctor-patient interactions with some patients expressing a sense of alienation arising from the use of technology, and problems with doctor-patient communication.

CONCLUSIONS

These data add significantly to the existing literature on patient satisfaction with telemedicine, by elucidating the factors underlying overall satisfaction scores and hence have implications for future service delivery and implementation of telemedicine.

Decision tools in health care: focus on the problem, not the solution

Background

Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing £5 billion in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint.

Discussion

Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem.

Summary

We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same.

Can subspecialty cancer consultations be delivered to communities using modern technology?--A pilot study

The objective of this project was to evaluate patient and physician acceptance of subspecialty oncologic teleconsultation for distant communities. Many newly diagnosed cancer patients have to travel several hours and long distances to attend specialty medical oncology consultations at our regional cancer center in Victoria, BC. Difficulties in recruiting of oncologists in Vancouver Island have prompted the search for other means to deliver subspecialty consultation closer to home. Teleconsultation seemed a possible model. Hence, 30 sequential patients with gastrointestinal (GI) malignancy referred from the Central Island region were seen after an informed consent via videoconferencing and 30 sequential patients were seen face to face in Victoria by one oncologist. Patients and the oncologist filled out a satisfaction questionnaire. The age, sex, proportion of patients who subsequently received chemotherapy, and the number of other co-morbid conditions were similar in both groups. No difference was observed in patient satisfaction whether patients were seen via videoconference or in person. However, the oncologist felt the video did not go as well as face-to-face consultation. Patients were very satisfied with teleconsultation, and it saved them hours of travel.

Clinical outcomes associated with telemedicine/telehealth

This paper is a comprehensive review and synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. It starts out with a brief description of the findings reported by similar literature reviews already published. Subsequently, it proposes a conceptual model for assessing clinical outcomes based on Donabedian's formulation of the Medical Care Process. Accordingly, research findings are reported in terms of the relevant components of the medical care process, namely, diagnosis, clinical management, and clinical outcomes. Specific findings are organized according to the designated clinical and diagnostic application. This is followed by a general report of studies dealing with patient satisfaction.

Teleconsultation with the mobile camera-phone in digital soft-tissue injury: a feasibility study

The purpose of this study was to examine the feasibility of teleconsultation using a mobile camera-phone to evaluate the severity of digital soft-tissue injury and to triage the injury with regard to management recommendations. With a built-in 110,000-pixel digital camera, pictures of the injured digit(s) or radiograph were taken by surgical residents in the emergency room and transmitted to another camera-phone to be viewed by the remote consultant surgeon. A brief medical and trauma history of each patient was relayed also by mobile phone. The consultant surgeon then reviewed all of these patients in the emergency room shortly after the initial telemedicine referral. Separate triaging for each digital injury into three groups was recorded during remote teleconsultation and according to actual treatment by the attending surgeon as follows: group I, the injury could be managed with conservative treatment, such as secondary intention wound healing, or primary closure with or without bone shortening; group II, skin grafting or local flap coverage was required for management of the injury; and group III, microsurgery such as replantation or free flap coverage was necessary to deal with the injury. Later, triaging was also performed individually by three junior plastic residents according to image review and patient referral information. Teleconsultation through a mobile camera-phone was performed for 45 patients with injuries of 81 digits from January to May of 2003. Of these 81 digital injuries, there were 12 cases (15 percent) where disagreement of triaging occurred between the teleconsultation and the actual treatment by the attending surgeon. In image reviewing, there was 79 percent sensitivity and 71 percent specificity in remote diagnosis of the skin defect and 76 percent sensitivity and 75 percent specificity in remote identification of the bone exposure regarding the concordance of opinions of all three surgeons; there was significant discordance in triaging in 20 cases (25 percent), and the difference in triaging was partly attributed to the inability to show instances of tiny exposed digital bone or tendon in some cases under the low-resolution digital image and the situation of a bloody oozing wound. In some cases, the difficulty in evaluating the probability of primary closure of severely avulsed skin edges or the probability of executing replantation for finger amputation also contributed to different triaging outcomes. Two neglected diagnoses of transected digital nerves were found and influenced triaging, highlighting the importance of on-site physical examination during teleconsultation. The telemedicine system using a mobile camera-phone based on the global system for mobile communication is feasible and valuable for early diagnosis and triaging of digital soft-tissue injury in emergency cases, with on-line verbal communication and review of the transmitted captured image. This system has the advantages of ease of use, low cost, high portability, and mobility. With advances in hardware for digital imaging and transmission technology and the development of the third-generation advanced mobile phone system in the foreseeable future, this system has potential for future applications in telemedicine and telecare.

Comorbidity and the use of primary care and specialist care in the elderly

PURPOSE

The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid conditions, and use of primary care and specialist services

METHODS

The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare files. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one first considered as the "main" one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system.

RESULTS

Higher morbidity burden was associated with more visits to specialists, but not to primary care physicians. Patients with most diagnoses had more visits, both to primary care and specialist physicians for comorbid diagnoses than for the main diagnosis itself. Although patients, especially those with high morbidity burdens, generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups; for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups.

CONCLUSION

In the elderly, a high morbidity burden leads to higher use of specialist physicians, but not primary care physicians, even for patients with common diagnoses not generally considered to require specialist care. This finding calls for a better understanding of the relative roles of generalists and specialists in the US health services system.

Teleconsultation by Using the Mobile Camera Phone for Remote Management of the Extremity Wound

To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.

Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science

People in remote Aboriginal communities in the Northern Territory have greater morbidity and mortality than other Australians, but face considerable barriers when accessing hospital-based specialist services. The Specialist Outreach Service, which began in 1997, was a novel policy initiative to improve access by providing a regular multidisciplinary visiting specialist services to remote communities. It led to two interesting juxtapositions: that of 'state of the art' specialist services alongside under-resourced primary care in remote and relatively traditional Aboriginal communities; and that of attempts to develop an evidence base for the effectiveness of outreach, while meeting the short-term evaluative requirements of policy-makers. In this essay, first we describe the development of the service in the Northern Territory and its initial process evaluation. Through a Cochrane systematic review we then summarise the published research on the effectiveness of specialist outreach in improving access to tertiary and hospital-based care. Finally we describe the findings of an observational population-based study of the use of specialist services and the impact of outreach to three remote communities over 11 years. Specialist outreach improves access to specialist care and may lessen the demand for both outpatient and inpatient hospital care. Specialist outreach is, however, dependent on well-functioning primary care. According to the way in which outreach is conducted and the service is organised, it can either support primary care or it can hinder primary care and, as a result, reduce its own effectiveness.

'Paper Clinics'- a model for improving delivery of outpatient colorectal services

OBJECTIVES

The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles.

METHODS

From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP.

RESULTS

During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review.

CONCLUSION

'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.

How do general practitioners rate their relationship with gastroenterologists?

BACKGROUND

Relations between general practitioners and the hospital consultants are often considered difficult, and occasionally generate conflicts, potentially affecting the patient management and healthcare system organisation. These views, however, have partly been contradicted by structured surveys and qualitative studies.

AIMS

We conducted a survey on the general practitioners' opinions regarding their relations with the gastroenterological-endoscopy services in order to explore current attitudes, any negative aspects and assess scope for improvement.

SUBJECTS AND METHODS

Structured questionnaires were sent to 221 general practitioners in the Veneto region of Italy; the questionnaire was based on 26 questions concerning their subjective relations with the gastroenterologists, expertise in the gastroenterological problems and perceived efficiency of gastroenterological services.

RESULTS

As many as 106 doctors answered the postal questionnaire (mean: 15 per province; range 5-20). Responses to the structured questions totalled to 2,339 items, out of which 1,234 (53%) presented positive responses, particularly with regard to admissions' management and the adequacy of referral reports. Many general practitioners reported of their participation in the meetings on gastroenterological problems. Homecare referrals were limited in number, even for the patients with tube feeding.

CONCLUSIONS

Relations between the general practitioners in Veneto and local gastroenterological services were generally good, possibly reflecting the well-developed outreach network. This liaison could be further improved via closer interrelations based not only on the patient referrals but also on the professional and information exchange to promote successful practice.

The effect of telemedicine on consultation time

We have implemented an 'evidence-based referral' for primary care patients in dermatology, cardiology and peripheral vascular disease. Telemedicine clinics bring together a district nurse, patient and vascular surgeon to discuss diagnosis, management and care. During a 30-month study, a total of 30 patients participated in telemedicine clinics. The mean consultation time fell from 23 to 10 min. In parallel, the type of consultation changed from dermatology to vascular surgery. Nineteen patients participated in vascular telemedicine clinics over the last 16 months of the study. The average consultation time was 10 min (SD 1), which included discussion of the case and negotiation of its management. The average consultation time in the equivalent outpatient clinic in the same hospital for the same consultant was 15 min. The acquisition of the relevant information in primary care could lead to a reduction of 75% in outpatient clinic appointments.

Why do telemedicine systems fail to normalize as stable models of service delivery?

Two groups independently carried out qualitative studies of the development, implementation and evaluation of telehealth systems and services in the UK. The data collected (in more than 600 discrete data collection episodes) included semistructured interviews, observations and documents. We conducted a conjoint reanalysis of the data. The objective was to identify the conditions which dispose a telehealth service to be successful or to fail. There appear to be four conditions necessary for a telemedicine system to stabilize and then normalize as a means of service delivery. When one or more is absent, failure can be expected. These conditions are often overlooked by local proponents of telemedicine, who seem to rely on demonstrations that the equipment works as the primary criterion of success.

Patient Followup After Radical Prostatectomy by Internet Medical File

PURPOSE

The development of the Internet and the need for regular followup of patients often living a long way from the hospital led us to develop a followup dossier for those with localized prostate cancer treated with laparoscopic radical prostatectomy.

MATERIALS AND METHODS

This feasibility study was based on 140 patients who agreed to test this system. The website was opened on a server specifically devoted to this project with all required computer security. The website is composed of pages comprising the hospital discharge summary, and operative and histology reports. A quality of life questionnaire based on the assessment of urinary continence and sex life, and a prostate specific antigen (PSA) assay form are also included.

RESULTS

The patient is able to enter his PSA data and complete the questionnaire at home. Results are then sent to the treating physician. A contact page allows the patient and physician to exchange information by text. Of these 100 patients 92 connected regularly to the site with a mean connection rate of 8 per patient (range 1 to 22). Of the patients 98% were satisfied with the various sections of the site, 95% were satisfied with the medical file, 11% noticed connection problems and 14% reported technical problems essentially attributable to incorrect PSA data entry or incorrect functioning of videos due to the absence of appropriate software.

CONCLUSIONS

This type of Internet medical service for patients who have undergone surgery requiring regular followup appears to be a useful approach for the future by allowing the maintenance of close contact between the patient and physicians, while avoiding problems related to hospital visits regardless of the patient place of residence. It also provides general practitioners with access to the patient file with patient permission.

Understanding the normalization of telemedicine services through qualitative evaluation

OBJECTIVE

Qualitative studies can help us understand the "successes" and "failures" of telemedicine to normalize within clinical service provision. This report presents the development of a robust conceptual model of normalization processes in the implementation and development of telemedicine services.

DESIGN

Retrospective and cumulative analysis of longitudinal qualitative data from three studies was undertaken between 1997 and 2002. Observation and semistructured interviews produced a substantial body of data relating to approximately 582 discrete data collection episodes. Data were analyzed separately in each of three studies. Cumulative analysis was conducted by constant comparison.

RESULTS

(1) Implementation of telemedicine services depends on a positive link with a (local or national) policy level sponsor. (2) Adoption of telemedicine systems in service depends on successful structural integration so that development of organizational structures takes place. (3) Translation of telemedicine technologies into clinical practice depends on the enrollment of cohesive, cooperative groups. (4) Stabilization of telemedicine systems in practice depends on integration at the level of professional knowledge and practice, where clinicians are able to accommodate telemedicine through the development of new procedures and protocols.

CONCLUSION

A rationalized linear diffusion model of "telehealthcare" is inadequate in assessing the potential for normalization, and the political, organizational, and "ownership" problems that govern the process of development, implementation, and normalization need to be accounted for. This report presents a model for assessing the potential for successful implementation of telehealthcare services. This model defines the requirements for the successful normalization of telemedicine systems in clinical practice.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.