Telemedicine: Pediatric Applications

Present and future of telemedicine for pediatric care: an Italian regional experience

Telemedicine has been recognized as an integral part of the National Health Service in Italy. Telemedicine can be adopted in the diagnostic therapeutic assistance pathway and in individual assistance plans. In the region of Lombardy, home care models from the perspective of the project of a public virtual hospital have been introduced. A regional operational center was proposed to ensure continuing care utilising organizational and technological solutions to deliver healthcare services remotely, with high quality standards, a positive economic impact and user friendly services for both the user and the professional. In the field of pediatrics telemedicine was also introduced at the Vittore Buzzi Children' Hospital, in Milan, the capital of the region of Lombardy. These included routine pediatric hospital activities and innovative programs, such as early discharge, telecardiology, online supervised exercise training and preventive healthcare. Telehealth represents the evolution of health care delivery systems to adapt to new technology and the needs of the pediatric population, offering a strategic system to invest in children's health.

Impact of the COVID-19 pandemic on the digitization of routine pediatric practice in Spain: A nationwide survey study

INTRODUCTION

The COVID-19 pandemic forced a change in the working dynamics of all healthcare professionals, leading to the sudden introduction of telemedicine. Although until that moment telemedicine applications had been described in the paediatric age, their use was anecdotal.

OBJECTIVE

To analyse the experience of Spanish paediatricians after the forced digitization of consultations due to the pandemic.

METHODS

A cross-sectional survey-type study was designed to obtain information from Spanish paediatricians about the changes that took place in the usual clinical practice.

RESULTS

306 health professionals participated in the study Most of them agreed on the use of the internet and social networks during the pandemic, referring to mail or WhatsApp® as usual channels of communication with their patients' families. There was a great agreement among paediatricians that the evaluation of newborns after hospital discharge and establishing methodologies that allow childhood vaccination and the identification of subsidiary patients for face-to-face evaluation were necessary although the limitations of the lockdown. The idea that telephone and digital consultations have optimized the consultation time and that they will probably continue after the end of the pandemic was generally accepted. No changes in adherence to breastfeeding or the start of complementary feeding were referred to, but an increase in the duration of breastfeeding and the appearance of frequent hoaxes in social networks concerning infant feeding were found.

CONCLUSIONS

It is necessary to analyse the impact of telemedicine in paediatric consultations during the pandemic to evaluate its effectiveness and quality to maintain it in routine paediatric practice.

Telehealth survey of providers and caregivers of children on peritoneal dialysis during the COVID-19 pandemic

BACKGROUND

There has been growing support for the adoption of telehealth (TH) services in pediatric populations. Children on chronic peritoneal dialysis (PD) represent a vulnerable population that could benefit from increased use of TH. The COVID-19 pandemic prompted rapid adoption of TH services in the population among pediatric centers participating in The Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric ESKD (SCOPE) Collaborative.

METHODS

We developed a survey to explore the experience of both pediatric PD providers and caregivers of patients receiving PD care at home and using TH services during the COVID-19 pandemic.

RESULTS

We obtained responses from 27 out of 53 (50.9%) SCOPE centers that included 175 completed surveys from providers and caregivers. Major challenges identified by providers included inadequate/lack of physical exam, inability to visit with the patient/family in-person, and inadequate/lack of PD catheter exit site exam. Only 51% of caregivers desired future TH visits; however, major benefits of TH for caregivers included no travel, visit takes less time, easier to care for other children, more comfortable for patient, and no time off from work. Providers and caregivers agreed that PD TH visits are family centered (p = 0.296), with the lack of a physical exam (p < 0.001) and the inability to meet in-person (p = 0.002) deemed particularly important to caregivers and providers, respectively.

CONCLUSIONS

TH is a productive and viable visit option for children on PD; however, making this a successful, permanent part of routine care will require an individualized approach with standardization of core elements. A higher resolution version of the Graphical abstract is available as Supplementary information.

Congestive heart failure clinics and telemedicine: The key to reducing hospital readmissions in the United States

The United States healthcare system currently faces an economic challenge related to frequent hospital readmission rates. As such, hospitals have begun implementing strategies to reduce readmission rates for specific medical conditions such as congestive heart failure, which had a 30-day readmission rate of 23.2% in 2014. Patient education and frequent monitoring of symptoms have since allowed patients to work together with doctors and nurses to take charge of their healthcare management. Due to heart failure clinics and the rise of telemedicine and telemonitoring, heart failure readmission rates have since decreased.

ETHICAL AND LEGAL ASPECTS OF TELEMEDICINE APPLIED IN ORTHOPEDICS

Due to the pandemic of COVID-19, many outpatient services were suspended, affecting hundreds of patients. As a result, several countries were forced to seek strategies to readapt their health systems, one of which was the expansion of telemedicine. Currently, telemedicine is used for several specialties, facilitating the treatment and follow-up of patients who have difficulty accessing it. Tele-orthopedics, telemedicine applied to the orthopedic specialty, allows orthopedic care to be offered to patients regardless of distance. By reducing travel time, waiting time, and costs, tele-orthopedics presents high patient satisfaction, allowing greater rehabilitation effectiveness after surgery and treatment compliance. There is much information in the current literature about telemedicine's legal and ethical aspects, but it is fragmented. This article aims to present a general explanation of these legal and ethical aspects, emphasizing tele-orthopedics. The ethical principles of autonomy, beneficence, non-maleficence and justice must be respected, as well the privacy and confidentiality during a teleconsultation. In this respect, orthopedic surgeons should be governed by traditional moral and ethical precepts. Still, they must also adapt to the new norms and laws regulating telemedicine use. Level of Evidence V: Expert Opinion.

Feasibility and Acceptability of Virtual Rounds on an Academic Inpatient Pediatric Unit

OBJECTIVES

Virtual rounds enable remote participation in bedside clinical encounters. Their effects on education remain poorly characterized and limited by lack of foundational evidence establishing that this approach is welcomed among learners and educators. We assessed technical feasibility and acceptability of incorporating video conferencing into daily work rounds of pediatric residents and attending physicians.

METHODS

We conducted a cross-sectional survey-based study of attending observers and pediatric residents participating in rounds both at the bedside and via video teleconferencing from September to December 2020. Participant experiences were assessed and summarized using parametric Likert-type questions regarding technical issues, efficiency, educational experience, and engagement. Associations between technical aspects and individual perceptions of virtual rounds and self-reported engagement were also measured.

RESULTS

Of 75 encounters, 29% experienced technical issues, 45% of which were attributable to a low-quality tablet stand. Negative impacts of virtual rounding on efficiency were reported in 6% of responses. Virtual participants were engaged (70%) and reported educational value for 65% of encounters. Comfort with virtually asking questions (odds ratio 3.3; 95% confidence interval 2.0-5.7) and performing clinical tasks for other patients (odds ratio 0.42; 95% confidence interval 0.2-0.9) were associated with engagement (P <.05).

CONCLUSIONS

Virtual participation in rounds was technically feasible and maintained educational value and engagement for residents in the majority of encounters, without sacrificing efficiency. Even as restrictions from the coronavirus disease 2019 pandemic are lifted, this rounding model has many important applications, including increasing educational opportunities for remote learners and making multidisciplinary rounds more accessible.

Parents’ satisfaction of tele-rehabilitation for children with neurodevelopmental disabilities during the COVID-19 pandemic

Background

The use of tele-rehabilitation in children was limited before the COVID-19 pandemic, due to culture, technology access, regulatory and reimbursement barriers.

Methods

The study was conducted according to the CHERRIES (Checklist for reporting results of internet E-surveys) guidelines in order to provide quantitative and qualitative data about experience of patients with disabilities and their caregivers during Phase 1 of the COVID-19 pandemic, and their level of satisfaction. An online survey was developed using Google Forms and sent via email. The outcome measures were rated using a 5-point Likert Scale. Two additional open-ended questions were used to collect qualitative data.

Results

One hundred twenty-eight out of 261 families responded to the survey: 80.5% of the caregivers reported they were satisfied with the tele-rehabilitation. More than a half (53%) of the families reported a high level of satisfaction with the involvement they received in defining and sharing of rehabilitation goals.

Conclusions

The implementation of telehealth during the COVID-19 lockdown has allowed us to gain more information about the potential of tele-rehabilitation, and resulted in an excellent satisfaction of caregivers. With appropriate education and consistent models of care, an increased use of telehealth may provide advances in remote patient care.

Trial registration

Not applicable.

Virtual Care Adoption-Challenges and Opportunities From the Lens of Academic Primary Care Practitioners

Telehealth and virtual care quickly became important tools in caring for patients while the COVID-19 pandemic evolved. Telehealth implementation can increase affordability for patients, eliminate access barriers, and improve patient satisfaction. Multiple challenges to successful telehealth implementation have been documented in the literature and are generally categorized as structural barriers of the health system, clinical barriers of the provider, and patient-centered barriers. In this study, we sought to collect themes and observations about this rapid transition to telehealth from practicing primary care clinicians, with the goal of identifying opportunities to improve adoption of telehealth. Themes reported in this article emerged from physician and physician assistant fellows of 2 HRSA-funded grants: (1) Primary Care Training and Enhancement (PCTE) and (2) Primary Care Training and Enhancement Training Primary Care Champions (Champions). The PCTE participants consisted of 8 providers from The MetroHealth System (MHS). The Champions participants consisted of 20 providers from MHS and Federally Qualified Health Centers in Northeast Ohio and Michigan. Participants identified 5 major themes that affected telehealth delivery in an academic medical system: reimbursement and productivity; social determinants of health; privacy and environment of care concerns; teaching; and communication skills. Examples within each theme are provided along with an identified improvement opportunity. As we create solutions to address these challenges, our hope is to pool our experience with others so that we can collectively learn how to best evolve and improve the telehealth experience for all.

Reshaping the Management of Allergic Rhinitis in Primary Care: Lessons from the COVID-19 Pandemic

The COVID-19 pandemic presented unique challenges to the delivery of healthcare for patients with allergic rhinitis (AR) following its disruption and impact on the healthcare system with profound implications. Reliance on self-care for AR symptom management was substantial during the pandemic with many patients encouraged to only seek in-person medical care when necessary. The advantage of digital technology becomes apparent when patients and healthcare providers had to change and adapt their method of interaction from the regular physical face-to-face consultation to telehealth and mobile health in the provision of care. Despite the pandemic and the ever-evolving post pandemic situation, optimal management of AR remains paramount for both patients and healthcare professionals. A reshaping of the delivery of care is essential to accomplish this goal. In this paper, we present what we have learned about AR management during the COVID-19 pandemic, the role of digital technology in revolutionizing AR healthcare, screening assessment in the identification and differentiation of common upper respiratory conditions, and a framework to facilitate the management of AR in primary care.

Demonstration experiment of telemedicine using ultrasonography and telerehabilitation with 5G communication system in aging and depopulated mountainous area

Objective

The challenges of an aging population worldwide are the increased number of people needing medical and nursing care and inadequate medical resources. Information and communication technologies have progressed remarkably, leading to innovations in various areas. 5G communication systems are capable of high-capacity, high-speed communication with low latency and are expected to transform medicine. We aimed to report a demonstration experiment of telerehabilitation and telemedicine using a mobile ultrasound system in a depopulated area in a mountainous terrain, where 32% of the population are 65 years or older.

Methods

At the core hospital, a physician or physical therapist remotely performed ultrasonography or rehabilitation on a subject in a clinic. Five general residents participated in the telerehabilitation as subjects. The delay time and video quality transmitted with 5G and long-term evolution (LTE) communication systems were compared. The physician or physical therapist subjectively evaluated the quality and delay of the transmitted images and subject acceptability.

Results

Of seven physical therapists, six and three responded that the video quality was "good" for telerehabilitation with 5G/4K resolution and LTE, respectively. Five physical therapists and one physical therapist reported that the delay time was "acceptable" with 5G/4K resolution and LTE, respectively. For telemedicine using a mobile ultrasound system, the responses for 5G were "the delay was acceptable" and "rather acceptable." In contrast, both respondents' responses for LTE were "not acceptable."

Conclusions

Multiple high-definition images can be transmitted with lower latency in telerehabilitation and telemedicine using mobile ultrasound imaging systems with a 5G communication system. These differences affected the subjective evaluation of the doctors and physical therapists.

A scoping review of the unassisted physical exam conducted over synchronous audio-video telemedicine

BACKGROUND

This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research.

METHODS

Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers.

RESULTS

Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter.

CONCLUSIONS

Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients' homes.

Is Endometriosis Telemedicine Friendly?

Objectives

Social isolation and lockdowns made telemedicine to gradually penetrate daily practice. Telemedicine has been used successfully in many areas of medicine such as psychiatry but is new in obstetrics and gynecology. This study aimed to investigate whether a telemedicine model would be feasible in choosing patients who needed face-to-face visits during the pandemic.

Materials and Methods

Telephone calls were conducted with patients with endometriosis who were admitted to our endometriosis clinic before the pandemic. The primary outcome was to appropriately triage the patients who could postpone their routine visit without any risk and those who needed an in-clinic appointment.

Results

Seventy-nine patients were included in the study. Among 58 patients who could be reached, 55 accepted to participate in the study. The mean length of the telephone calls was 8.17 min. Nine patients required an in-clinic appointment (16.4%), whereas 46 (83.6%) patients were managed with the phone call. Compliance with hormonal agents for the treatment of endometriosis-associated pain was 11/17 (64.7%). The most commonly asked questions by patients were about cervical screening, fertility cryopreservation, and the medical treatment options of endometriosis.

Conclusion

Telemedicine visits can never replace in-clinic practice but can help with a considerable degree of efficacy in the management of patients with endometriosis.

Strategies for implementation of virtual home visitation in the United States

Utilising telepractice videoconferencing technology to offer home visitation services has the potential to provide access and parenting support through a high-tech and high-touch service delivery option. Families can receive evidence-based, family support intervention from their home via videoconferencing technology, removing the need for the provider to be physically in the home. While the expansion of telehealth and telepractice services for families is essential for meeting the needs of both parents and their children, well-documented engagement barriers to digital health/computer-mediated interventions exist across treatment modalities and technology platforms. Semi-structured interviews with 15 providers were conducted and analysed to identify engagement strategies utilised to sustain families in a home visitation model offered through live videoconferencing technology on a telehealth platform. Analysis revealed four themes that were deemed essential for successfully attracting and maintaining families in a telepractice-based home visitation programme: (a) engagement strategies to encourage families to participate; (b) clinical skills used within sessions; (c) articulation of benefits to the family; and (d) exploration of rationale for ending services. This study was able to identify strategies for engagement and sustained involvement of families in telehealth-based home visitation. Findings include evidence that providers should be able to move between telehealth and on-ground service provision with relative ease.

Primary Care Visits Are Timelier When Patients Choose Telemedicine: A Cross-Sectional Observational Study

Introduction: Telemedicine could increase timely access to primary care-a key dimension of care quality. Methods: Among patient-scheduled appointments with their own primary care providers using the online portal in a large integrated health care delivery system, we measured the association between visit type (telemedicine or in-person) and appointment timeliness. We calculated the calendar days between the scheduling date and the actual appointment time. Results: Overall, 2,178,440 primary care visits were scheduled and 14% were done through telemedicine. The mean calendar days between the scheduling and the appointment time were 1.80 for telephone visits, 2.29 for video visits, and 3.52 for in-person visits. After multivariate adjustment, 66.61% (confidence interval [95% CI]: 66.44-66.79) of telephone visits, 56.58% (95% CI: 55.90-57.27) of video visits, and 46.49% (95% CI: 46.42-46.57) of in-person visits were scheduled to occur within 1 day of making the appointment. Conclusions: In a setting with comparable in-person and telemedicine scheduling availability, choosing telemedicine was associated with more timely access to primary care.

La prestation de soins virtuels et novateurs dans un centre pédiatrique canadien de soins tertiaires

Les systèmes de santé et les travailleurs de la santé se sont rapidement adaptés à la prestation des soins virtuels pendant cette période sans précédent. Les programmes cliniques ont adopté divers modèles de soins virtuels pour maintenir l’accès, économiser l’équipement de protection individuelle et limiter la propagation des maladies infectieuses. Dans le présent article, les auteurs décrivent d’abord le contexte de prestation des soins pédiatriques pendant la pandémie de COVID-19 au Canada, laquelle a propulsé la prestation des soins virtuels. Ils résument ensuite la préparation, la mise en œuvre et les effets bénéfiques des programmes de soins virtuels utilisés actuellement au Centre hospitalier pour enfants de l’est de l’Ontario (CHEO), tant pour les patients hospitalisés que non hospitalisées, notamment dans les cliniques ambulatoires, aux urgences et au sein du programme de santé mentale. Ils soulignent les moyens transférables et particuliers qu’a retenus le CHEO pour intégrer la prestation des soins virtuels, que ce soit au moyen de sa structure de gouvernance, de la participation des intervenants – y compris les patients, les proches, les travailleurs de la santé et le personnel –, de la préparation et de l’utilisation des outils de télésanté et des approches novatrices de soins aux patients qui ont besoin d’une évaluation physique. Ils concluent en présentant leur vision de l’avenir des soins virtuels, qui feront partie de l’arsenal des soins pédiatriques après la pandémie de COVID-19, mais qui devront être soumis à un cadre commun d’évaluation.

Fait important, la mise en œuvre rapide d’un modèle de soins principalement virtuels au CHEO a favorisé le maintien d’un volume élevé de soins pédiatriques de qualité. Selon les auteurs, bon nombre de ces programmes devraient être conservés et le seront bel et bien après la pandémie. Il est essentiel d’adopter une approche exhaustive et unifiée de l’évaluation pour obtenir des résultats constructifs qui inspireront des modèles de prestation des soins pérennes, incluant les soins virtuels, et qui contribueront à garantir le meilleur pronostic possible pour les patients.

Factors Influencing Procurement of Digital Healthcare: A Case Study in Dutch District Nursing

BACKGROUND

Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing.

METHODS

A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports.

RESULTS

Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side.

CONCLUSION

This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.

Trends in Telehealth Antibiotic Prescribing for Children Through the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Telehealth visits increased significantly during the coronavirus disease 2019 pandemic without consensus on the appropriate scope of telehealth antibiotic prescribing within pediatric primary care. We describe telehealth antibiotic prescribing patterns within our statewide pediatric primary care network during the coronavirus disease 2019 pandemic.

METHODS

In a retrospective observational study of a large statewide pediatric primary care network, we identified and analyzed telehealth and in-person encounters with oral antibiotics prescribed from March 2020 to July 2021. We focused on the top 5 general diagnosis groupings using International Classification of Disease 10 codes.

RESULTS

Of the 55 926 encounters with an oral antibiotic prescribed, 12.5% were conducted via telehealth and 87.5% in person. The proportion of telehealth antibiotic encounters varied significantly according to diagnosis category (P <.001): ear (30.8%), skin and subcutaneous (21.8%), respiratory (18.8%), genitourinary (6.3%), and Lyme disease infections (3.8%). The proportion of telehealth antibiotic encounters for all diagnosis categories peaked in spring of 2020. The greatest proportion of telehealth antibiotic prescribing during the most recent 4weeks of the analysis were Lyme disease infections (11.7%) and for skin and subcutaneous tissue infections (3.1%).

CONCLUSIONS

Telehealth continues to be used to prescribe antibiotics even after the initial stage of the pandemic. Clinicians and patients would benefit from clearer guidelines about the appropriate use of antibiotics prescribed during telehealth encounters.

COVID-19 Pandemic and Remote Consultations in Children: A Bibliometric Analysis

Telemedicine is becoming a standard method of consultation, and the COVID-19 pandemic has increased its need. Telemedicine is suitable for non-communicable diseases (NCDs) in the pediatric population, as these are chronic conditions that affect many children worldwide. The aim of this study was to analyze the bibliometric parameters of publications on the use of telemedicine for the most common NCDs in children before and after the COVID-19 pandemic. Following the electronic search, 585 records were selected. "Metabolic diseases" was the most frequent topic before and after the pandemic, accounting for 34.76% in 2017-2019 and 33.97% in 2020-2022. The average IF of the journals from which records were retrieved was 5.46 ± 4.62 before and 4.58 ± 2.82 after the pandemic, with no significant variation. The number of citations per reference averaged 14.71 ± 17.16 in 2017-2019 (95% CI: 12.07; 17.36) and 5.54 ± 13.71 in 2020-2022 (95% CI: 4.23; 6.86). Asthma, metabolic diseases, and neurodevelopmental disorders were the most explored topics. A relevant finding concerns the increasing number of observational studies after the pandemic, with a reduction of the interventional studies. The latter type of study should be recommended as it can increase the evaluation of new strategies for the management of NCDs.

Applications of Telemedicine in Dermatology

Telemedicine is a technological tool that enhances well-being all around the globe. Practicing medicine or performing a clinical examination from a distance was a mere thought until this decade's pandemic hit the world. Telemedicine is practicing medicine sitting on one side of a globe and diagnosing and treating a different individual from the opposite part of the world. There is a long way to go for medical practitioners to execute an entire clinical examination analogous to an accurate clinical examination. Telemedicine is a supplement to a patient's total care, not a replacement for in-person doctor visits. Family doctors can easily access specialists using telemedicine, which enables them to monitor their patients closely. Numerous telemedicine systems, including store and forward, real-time and remote, or self-monitoring, are used worldwide for education, healthcare delivery and control, sickness screening, and disaster management. Even if telemedicine cannot solve every issue, it can significantly lessen the strain on the healthcare system. Nevertheless, investigations performed via telemedicine have started incorporating various medical instruments called telemedicine peripherals, including electronic stethoscopes, teleophthalmoscopes, and video-otoscopes. The prevailing disease around the globe of coronavirus has remarkably debilitated the medical infrastructure in providing diagnosis, treatment, monitoring, and follow-ups. As a result, there is a significant change in the way of practicing medicine and managing patients. Telemedicine provides timely patient care and reduces the risk of exposure to various communicable diseases offered to medical practitioners. The development of imaging technologies has significantly impacted dermatology, a specialty that relies on visual signals. Reviewing dermatology's existing situation and potential digital future, in brief, is the goal of this study. This study provides brief information on telemedicine, its application and scope in dermatology, and how it can alter the healthcare system.

Impact of coronavirus disease-2019 on pediatric nephrology practice and education: an ESPN survey

BACKGROUND

Coronavirus disease-2019 (COVID-19) has been challenging for patients and medical staff. Radical changes have been needed to prevent disruptions in patient care and medical education.

METHODS

A web-based survey was sent to European Society for Pediatric Nephrology (ESPN) members via the ESPN mailing list to evaluate the effects of the COVID-19 pandemic on delivery of pediatric nephrology (PN) care and educational activities. There were ten questions with subheadings.

RESULTS

Seventy-six centers from 24 countries completed the survey. The time period was between the beginning of the pandemic and May 30, 2020. The number of patients admitted in PN wards and outpatient clinics were significantly decreased (2.2 and 4.5 times, respectively). Telemedicine tools, electronic prescriptions, online applications for off-label drugs, and remote access to laboratory/imaging results were used in almost half of the centers. Despite staff training and protective measures, 33% of centers reported COVID-19 infected staff, and 29% infected patients. Difficulties in receiving pharmaceuticals were reported in 25% of centers. Sixty percent of centers suspended living-related kidney transplantation, and one-third deceased-donor kidney transplantation. Hands-on education was suspended in 91% of medical schools, and face-to-face teaching was replaced by online systems in 85%. Multidisciplinary training in PN was affected in 54% of the centers.

CONCLUSIONS

This survey showed a sharp decline in patient admissions and a significant decrease in kidney transplantation. Telemedicine and online teaching became essential tools, requiring integration into the current system. The prolonged and fluctuating course of the pandemic may pose additional challenges necessitating urgent and rational solutions.

A Pediatrician's Guide to Working with Children on the Autism Spectrum in Coronavirus Disease 2019 and Beyond: Retrospect and Prospect

The COVID-19 pandemic is an unprecedented event with devastating effects on children and families, highlighting and broadening disparities in the care of children with developmental disabilities, while simultaneously catalyzing innovation. Children are vulnerable to the impacts of COVID-19, resulting in increased stress, anxiety, isolation, and health challenges, further amplified in autistic children and children with other neurodevelopmental disabilities. These children are uniquely vulnerable due to communication impairments, comorbid medical disorders, reduced adaptability, and reliance on therapeutic interventions. Abrupt reduction in services and access to care during the pandemic compromised physical and mental health and led to missed intervention opportunities at critical times. It is important to examine the effects that the pandemic triggered, address deficiencies, and recognize new opportunities to improve systems of care to prepare for unforeseen futures.

Remote Versus In-person Outpatient Clinic Visits and Antibiotic Use Among Children During the COVID-19 Pandemic

BACKGROUND

The proportion of remote clinic visits was expected to increase among children during the COVID-19 pandemic which might result in antibiotic overuse.

METHODS

In southern Israel, 2 ethnic groups, Jewish and Bedouin, live side-by-side. Computerized data on visits for children <18 years were examined from clinics with ≥50 insured children, active both pre-COVID-19 and during the COVID-19 pandemic. Visits were divided into in-person and remote. Monthly infectious diagnoses and dispensed antibiotic prescription rates were calculated by age (<5, 5-17 years) and ethnic groups. Mean monthly rates of 2 parallel seasons (pre-COVID-19 and COVID-19 periods) were compared.

RESULTS

Overall 2,120,253 outpatient clinic visits were recorded. Remote clinic visit rates (per 1000 children) increased from 97.04 and 33.86 in the pre-COVID-19 to 179.75 and 50.05 in the COVID-19 period in Jewish and Bedouin children, respectively ( P < 0.01) along with a reduction of in-person visit rates in both populations. Comparing pre-COVID-19 and COVID-19 periods, the rates of overall infectious diagnoses in remote visits increased. Nevertheless, dispensed antibiotic prescription rates in remote visits (per 1000 visits) remained unchanged (9.84 vs. 8.67, P = 0.70, in the Jewish population and 14.32 vs. 14.17, P = 1.00, in the Bedouin population in the pre-COVID-19 and COVID-19 periods, respectively) with a similar distribution of antibiotic categories.

CONCLUSIONS

COVID-19 pandemic resulted in an expansion of remote visits of children <18 years with an increase in infectious diagnoses. However, remote dispensed antibiotic prescription rates remained unchanged. These dynamics were more accentuated in Jewish children, characterized by higher socio-economic conditions, compared to Bedouin children.

Telemedicine System Applicability Using Drones in Pandemic Emergency Medical Situations

Drones have evolved significantly in recent years, acquiring greater autonomy and carrier capacity. Therefore, drones can play a substantial role in civil medicine, especially in emergency situations or for the detection and monitoring of disease spread, such as during the COVID-19 pandemic. The aim of this paper is to present the real possibilities of using drones in field rescue operations, as well as in nonsegregated airspace, in order to obtain solutions for monitoring activities and aerial work in support of the public health system in crisis situations. The particularity of our conceptual system is the use of a “swarm” of fast drones for aerial reconnaissance that operate in conjunction, thus optimizing both the search and identification time while also increasing the information area and the operability of the system. We also included a drone with an RF relay, which was connected to a hub drone. If needed, a carrier drone with medical supplies or portable devices can be integrated, which can also offer two-way audio and video communication capabilities. All of these are controlled from a mobile command center, in real time, connected also to the national dispatch center to shorten the travel time to the patient, provide support with basic but life-saving equipment, and offer the opportunity to access remote or difficult-to-reach places. In conclusion, the use of drones for medical purposes brings many advantages, such as quick help, shortened travel time to the patient, support with basic but life-saving equipment, and the opportunity to access remote or difficult-to-reach places.

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training

PURPOSE

To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees.

METHODS

We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training.

RESULTS

Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier.

CONCLUSIONS

Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.

Experience of Pediatricians and Pediatric Surgeons With Virtual Care During the COVID-19 Pandemic: Descriptive Study

BACKGROUND

Prior to the COVID-19 pandemic, in-clinic visits were the standard of care for pediatric physicians and surgeons at our center. At the pandemic onset, web-based care was adopted at an unprecedented scale and pace.

OBJECTIVE

This descriptive study explores the web-based care experience of pediatric physicians and surgeons during the pandemic by determining factors that supported and challenged web-based care adoption.

METHODS

This study took place at the Children's Hospital at London Health Sciences Centre, a children's hospital in London, Ontario, Canada, which provides pediatric care for patients from the London metropolitan area and the rest of Southwestern Ontario. The Donabedian model was used to structure a web-based survey evaluating web-based care experience, which was distributed to 121 department-affiliated pediatric physicians (including generalists and subspecialists in surgery and medicine). Recruitment occurred via department listserv email. Qualitative data were collected through discrete and free-text survey responses.

RESULTS

Survey response rate was 52.1% (63/121). Before the pandemic, few physicians within the Department of Paediatrics used web-based care, and physicians saw <10% of patients digitally. During March-May 2020, the majority transitioned to web-based care, seeing >50% of patients digitally. Web-based care use in our sample fell from June to September 2020, with the majority seeing <50% of patients digitally. Telephone and Ontario Telemedicine Network were the platforms most used from March to September 2020. Web-based care was rated to be convenient for most providers and their patients, despite the presence of technical difficulties. Challenges included lack of physical exam, lower patient volumes, and poor patient digital care etiquette. Regardless of demographics, 96.4% (116/121) would continue web-based care, ideally for patients who live far away and for follow-ups or established diagnoses.

CONCLUSIONS

Transition to web-based care during COVID-19 was associated with challenges but also positive experiences. Willingness among pediatricians and pediatric surgeons to continue web-based care was high. Web-based care experiences at our center could be improved with patient education and targeting select populations. Future research is needed to improve practice efficiency and to inform regulatory guidelines for web-based care.

The Self-Efficacy of Physicians to Communicate With Patients via Telemedicine in Lieu of Face-to-Face Visits in Light of the COVID-19 Pandemic: An Observational Study

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has perpetuated the switch to increased use of telemedicine for initial consultations for physicians out of the necessity of reducing face-to-face contact. It has not been thoroughly studied whether physicians are as self-efficacious in their ability to communicate virtually versus in person considering the natural difficulty of obtaining some objective data points such as those coming from physical examination techniques via telemedicine.

Methods: The Self Efficacy-12 (SE-12) questionnaire, a physician validated objective measure, was used to assess 101 physicians (96% response rate) from 29 specialties for their self-efficacy when communicating with patients when consulting virtually versus in person.

Results: There was a significant 32.43% decrease (p=<0.01) in physician self-efficacy when a patient was evaluated via telemedicine for the first time.

Conclusion: The significant decrease in self-efficacy provides initial evidence that initial consultations should be done in person to maximize physician self-efficacy when communicating with patients.

Innovative virtual care delivery in a Canadian paediatric tertiary-care centre

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children's Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Access to Services for Children and Youth With Special Health Care Needs and Their Families: Concepts and Considerations for an Integrated Systems Redesign

Access to services for children and youth with special health care needs (CYSHCN) have typically emphasized coverage, service, timeliness, and capability. Yet families of CYSHCN continue to describe a fragmented health care system with significant unmet needs. For many years, the concept of access to services has focused on the services themselves, rather than starting with the needs of CYSHCN and their families. Meeting these needs should be grounded in health equity, address systemic racism and ableism, and emphasize the life course and journey of those with such needs and their families. In this paper, we start with the simple concept of asking that care is available for CYSHCN regardless of when, where, and how they need it. Access to services is built on relationships instead of a series of transactions. Opportunities for innovation include creating a single point of service entry; determining services based on need instead of diagnosis; and emphasizing service continuity, transition, and a place-based approach. The innovations reimagine access throughout the life course, centering care around a proactive, human-centered system that addresses health and all of its determinants. The landscape of antipoverty investments, cultural humility, workforce changes, technology, and human-centered thought in design have the potential to further transform the conceptual framework to improve access to services for CYSHCN and their families.

Combining patient-specific, digital 3D models with tele-education for adolescents with CHD

INTRODUCTION

Adolescents with CHD require transition to specialised adult-centred care. Previous studies have shown that adolescents' knowledge of their medical condition is correlated with transition readiness. Three-dimensional printed models of CHD have been used to educate medical trainees and patients, although no studies have focused on adolescents with CHD. This study investigates the feasibility of combining patient-specific, digital 3D heart models with tele-education interventions to improve the medical knowledge of adolescents with CHD.

METHODS

Adolescent patients with CHD, aged between 13 and 18 years old, were enrolled and scheduled for a tele-education session. Patient-specific digital 3D heart models were created using images from clinically indicated cardiac magnetic resonance studies. The tele-education session was performed using commercially available, web-conferencing software (Zoom, Zoom Video Communications Inc.) and a customised software (Cardiac Review 3D, Indicated Inc.) incorporating an interactive display of the digital 3D heart model. Medical knowledge was assessed using pre- and post-session questionnaires that were scored by independent reviewers.

RESULTS

Twenty-two adolescents completed the study. The average age of patients was 16 years old (standard deviation 1.5 years) and 56% of patients identified as female. Patients had a variety of cardiac defects, including tetralogy of Fallot, transposition of great arteries, and coarctation of aorta. Post-intervention, adolescents' medical knowledge of their cardiac defects and cardiac surgeries improved compared to pre-intervention (p < 0.01).

CONCLUSIONS

Combining patient-specific, digital 3D heart models with tele-education sessions can improve adolescents' medical knowledge and may assist with transition to adult-centred care.

Comprehensive analysis of 65 patients with Castleman disease in a single center in China

This study aimed to investigate the epidemiologic, clinical, pathological characteristics, and treatment of patients with Castleman disease (CD) in a single center in China. We retrospectively analyzed the data of 65 Chinese CD patients, divided into unicentric CD (UCD) and multicentric CD (MCD) groups, and also microscopic subtypes as hypervascular (HV), plasmacytic (PC) and Mixed. Based on whether HHV-8 infection existed, MCD was subdivided into HHV-8-associated MCD and idiopathic Castleman disease (iMCD). Detailed epidemiologic, clinicopathological, and treatment data were analyzed and discussed. Of total 65 patients (UCD 33, MCD 32), HV (81.8%) accounted for the most of UCD and total. More females in UCD (60.6%) and more males in MCD (65.6%) were observed. CD occurred in all age groups, most commonly in 40-49 years. The mean age of onset of total was 38.5 years with PC higher than HV (45.5 vs. 35.1 years, P = 0.0413). The median diagnosis delay of MCD was longer than that of UCD (3.00 vs. 1.25 months, P = 0.0436). Abdomen (39.4%) and neck (30.3%) were the most-seen locations of lymphadenopathy in UCD, with neck (65.6%) being predominant in MCD. Mean major diameter of specimens of UCD was greater than MCD (6.4 vs. 3.1 cm, P < 0.0001). These results provided the featured and detailed profile of Castleman disease in Henan province in China with a considerable number of cases, which presented distinct evidence with other studies.

Preoperative virtual video visits only: a convenient option that should be offered to caregivers beyond the pandemic

Objective

During the COVID-19 pandemic, our group implemented preoperative video visits (VVs) to limit physical contact. The aim of this study was to determine caregivers’ and providers’ perceptions of this practice and to determine feasibility for continuation.

Methods

All patients who had only a preoperative VV prior to an elective surgery were identified from March–October 2020. Caregivers, surgeons, and clinic staff were surveyed about their experiences.

Results

Thirty-four preoperative VVs were followed by an elective surgery without a preceding in-person visit. Of the 31 caregiver surveys completed, the majority strongly agreed that the VV was more convenient (87%, n=27). Eighty-one percent (n=25) strongly agreed or agreed that the VV saved them money. Ninety-four percent (n=29) strongly agreed or agreed that they would choose the VV option again. Caregivers saved an average travel distance of 60.3 miles one way (range 6.1–480). Of the 13/17 providers who responded, 77% (n=10) expressed that the practice should continue.

Conclusions

Virtual health became a necessity during the pandemic, and caregivers were overwhelmingly satisfied. Continuing VVs as an option beyond the pandemic may be a reasonable and effective way to help eliminate some of the hurdles that impede healthcare-seeking behavior and should be offered.

Video Telehealth Access and Changes in HbA1c Among People With Diabetes

INTRODUCTION

Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c.

METHODS

This longitudinal cohort study (2016-2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) during video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses were conducted in September 2020.

RESULTS

Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= -0.19, -0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (-0.22 percentage points, 95% CI= -0.32, -0.11) and with no baseline HbA1c measurement (-0.39 percentage points, 95% CI= -0.71, -0.07).

CONCLUSIONS

Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.

Examining the Utility of Preoperative Telemedicine Care Across Multiple Pediatric Surgery Disciplines

INTRODUCTION

Telemedicine use within pediatric surgery fields has been growing, but research on the utility of remote evaluation in the perioperative period remains scarce. The objective of this study was to examine the utility of perioperative telemedicine care for the pediatric patient by evaluating the outcomes following completion of an outpatient appointment with a surgical provider.

MATERIALS AND METHODS

We performed a retrospective chart review of all patients who completed a telemedicine appointment with a provider across nine pediatric surgery divisions, without a limitation based on patient-specific characteristics or telemedicine platform. We examined the result of the initial telemedicine appointment and the outcome of any surgical procedure that was performed as a result.

RESULTS

A total of 803 patients were evaluated by telemedicine during the study period. Of the 164 encounters (20.2%) that were followed by a surgery, nearly 70% were performed using a video. There was no discordance in the preoperative and postoperative diagnoses for more than 98% of patients. Nearly 25% of operations were followed by at least a 1-night hospital stay and 6.7% of patients developed a postoperative complication.

CONCLUSIONS

Telemedicine is a safe tool for evaluating pediatric patients in the preoperative and postoperative phases of care and offers potential value for families seeking an alternative to the traditional in-person appointment. Ongoing support will require permanent legislative changes aimed at ensuring comparable compensation and the development of strategies to adapt the outpatient healthcare model to better accommodate the evolving requirements of remotely evaluating and treating pediatric patients.

Telemedicine application in patients with chronic disease: a systematic review and meta-analysis

Background

Telemedicine has been widely used for long-term care and self-management in patients with chronic disease, but there is no consensus regarding the effect of telemedicine on chronic disease management. The aim of this study is to review and analyse the effect of telemedicine on the management of chronic diseases such as hypertension, diabetes, and rheumatoid arthritis using a systematic review and meta-analysis.

Methods

We performed a comprehensive literature search of the Web of Science, PubMed, MEDLINE, EMBASE, CNKI (Chinese database), VIP (Chinese database), WanFang (Chinese database), and SinoMed (Chinese database) databases from their inception until December 31, 2021. The retrieved literature was screened and assessed independently by two authors. We used the risk-of-bias assessment tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions 5.0.2 for assessing literature quality and Revman 5.3 software to conduct the meta-analysis.

Results

Fifteen articles were included in this study. The results of the systematic review indicated that telemedicine consultation and telemonitoring are the most commonly used intervention methods. Telemedicine is helpful for improving self-management in patients with rheumatoid arthritis. The results of the meta-analysis showed patients’ index of glycosylated hemoglobin (HbA1c) improved after 12 months of intervention (MD =  − 0.84; 95% CI =  − 1.53, − 0.16; Z = 2.42; P = 0.02), and no significant differences in fasting blood glucose (FBG) levels were observed after 6 months of intervention (MD =  − 0.35; 95% CI =  − 0.75,0.06; Z = 1.69; P = 0.09). The results also showed that systolic blood pressure (MD =  − 6.71; 95% CI =  − 11.40, − 2.02; Z = 2.81; P = 0.005) was reduced after 6 months of intervention.

Conclusion

Telemedicine had a positive effect on the management of diabetes, hypertension, and rheumatoid arthritis, especially when telemedicine consultation and telemonitoring method were used. When telemedicine was used as a disease management tool for patients with diabetes, the optimal intervention time is 12 months. Telemedicine improved the systolic blood pressure in hypertensive patients while also reducing negative emotions and enhancing medication adherence in rheumatoid arthritis patients.

The Use of Telemedicine in Pediatric and Adolescent Gynecology

STUDY OBJECTIVE

To study the feasibility of virtual visits for ambulatory encounters in pediatric and adolescent gynecology DESIGN: A retrospective review SETTING: Boston Children's Hospital PARTICIPANTS: Patients who were seen virtually through the Division of Gynecology between January 1, 2020 and June 1, 2020 MAIN OUTCOME MEASURE(S): Patient demographics, visit diagnoses, and operational characteristics of the completed visits RESULTS: There were a total of 654 virtual visits for 614 patients. Ninety-one percent (n=558) of patients were in-state, and the median age of patients was 17 years (range 0 - 37 years). The majority were return visits (n=502, 76.8%), 115 (17.6%) were new patient visits, and 32 (4.89%) were post-operative visits. The median virtual visit duration was 12 minutes and 39 seconds (range 5 minutes to over 1 hour). The most common gynecologic diagnoses were dysmenorrhea/endometriosis (n=485, 74.2%), abnormal uterine bleeding (n=225, 34.4%), and pelvic pain (n=82, 12.5%). The percentage of virtual visits which required an in-person follow-up visit within 90 days was low (n=14, 2.1%). Five of these were within 30 days from the initial virtual visit, 6 were within 60 days, and 3 were within 90 days.

CONCLUSION

Telemedicine is a feasible method for expanding access to, and healthcare delivery for, pediatric and adolescent gynecology, with low rates of short interval in-person follow-up required. Virtual visits can be conducted for a range of patients with a variety of gynecologic conditions, upon initial presentation and follow-up.

Pediatric apps: what are they for? A scoping review

In recent years, there has been a surge in the development of mHealth apps. Nevertheless, there are no scoping reviews that analyze the scientific peer-reviewed articles of these tools. This research systematically reviews the scientific literature published on health apps targeting children in peer-reviewed journals. It aims to answer four questions: what is the primary purpose of these apps; for what medical specialties and main topics were they developed; whom do they target; and how they were analyzed. The study followed PRISMA methodology, and the search process used the Web of Science Core Collection. The selected terms for the search were "pediatr*" and "app." The initial search resulted in 303 papers which, after applying filters, excluded 187 papers. In the end, 116 articles were deemed appropriate for addressing our research questions and were thoroughly reviewed. The primary purpose of pediatric health apps is to support clinical decision-making, patient education, and patient self-management. The most frequent topics covered are cancer, obesity, and asthma. Hematological oncology and endocrinology are the most frequent medical specialties addressed. The apps mainly target children, their caregivers, or both groups. Most of the apps were analyzed using observational studies, predominantly conducted in the USA, with an average participant sample size of 842. No analyses of development costs were found. These findings can be helpful for the development of future pediatric health apps. What is Known: • Health care has become increasingly digital due to digital health technologies, which have helped to expand the scope of health care. • Digital health technology can be used to improve the health of children. • The increasing availability of smartphones for children and families may enable the use of apps to deliver, promote, and sustain interventions which could lead to long-term improvements in health. What is New: • The most frequent topics covered were cancer, obesity, and asthma. Hematology-oncology and endocrinology were the most frequent medical specialties addressed. • The principal aims of the pediatric health apps were to facilitate clinical decision support, patient education, and patient self-management. • The apps mainly targeted children, their caregivers, or both groups. • Most of them had been analyzed using observational studies.

Telemedicine applied to neuromuscular disorders: focus on the COVID-19 pandemic era

Neuromuscular diseases are rare and usually chronic progressive disorders that require a multidisciplinary clinical evaluation and functional monitoring. The patient-physician relationship and therapies are also key elements to be provided. The COVID-19 pandemic dramatically changed the way patients' health was managed and national health care services underwent a radical reorganization. Telemedicine, with the use of Information and Communication Technology (ICT) by health professionals, became the main strategy to ensure the continuation of care. However, the experience regarding the use of Telemedicine in neuromuscular disorders is very limited and the scientific literature is extremely scarce. From the first experiences in the '50s, the development of Telemedicine has been supplemented and supported by the implementation of ICT to guarantee the secure and effective transmission of medical data. Italian national guidelines (2010-2020) describe the technical and professional guarantees necessary to provide Telemedicine services. Nevertheless, at the time the pandemic appeared, no guidelines for clinical evaluation or for the administration of functional scales remotely were available for neuromuscular diseases. This has been a critical point when clinical evaluations were mandatory also for the renewal of drug prescriptions. However, the common opinion that telemedicine basic services were important to overcome the change in medical practice due to COVID-19 in neuromuscular diseases, even in pediatric age, emerged. Moreover, alternative digital modalities to evaluate patients at home in a kind of virtual clinic were considered as a field of future development.

Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care

Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.

Patient Satisfaction in Neurodevelopmental Pediatrics: In-Person vs Telemedicine

BACKGROUND

As a result of the COVID-19 pandemic, medical practices for children with neurodevelopmental disorders urgently adopted telehealth, despite limited data regarding patient satisfaction.

OBJECTIVE

To compare patient satisfaction survey scores for neurodevelopmental pediatric appointments completed in-person to appointments completed via telemedicine.

METHODS

Using routinely collected Press Ganey survey results, the proportion of Top Box scores (the percentage of responses in the highest possible category [ie, the percentage of "very good" or "always" responses]) for an in-person only group was compared to the proportion in a telemedicine-only group using Fisher's exact test.

RESULTS

Most respondents gave Top-Box scores in response to all of the questions for both in-person and telemedicine visits. There were no statistically significant differences in any domain of the Press Ganey surveys in Top Box percentages for in-person vs telemedicine visits.

CONCLUSION

This study provides preliminary evidence that telehealth may be an acceptable modality for families seeking care for their children with neurodevelopmental concerns.

The Impact of the COVID-19 Pandemic on Pediatric Graduate Medical Education: Lessons Learned and Pathways Forward

In this article, the authors describe the impact of the COVID-19 pandemic on pediatric graduate medical education (GME), including the impact on clinical experiences for trainees, teaching methods used, trainee wellness, GME leader wellness and support, and the traditional interview process. A thorough literature review was done to identify impacts of the COVID-19 pandemic on pediatric GME. In addition, information was collected through Association of Pediatric Program Directors virtual cafes and conferences. Positive changes for GME from the COVID-19 pandemic included: the rapid transition to telehealth; asynchronous learning allowing for increased cross-program collaboration; innovative online teaching modalities; increased flexibility and decreased cost of online recruitment; and shared innovations across pediatric GME. Challenging aspects of the COVID-19 pandemic included: decreased learning about common childhood illnesses, such as bronchiolitis, acute otitis media, and influenza; decreased patient volumes and patient complexity in clinics and inpatient wards, leading to less practice developing efficiency, time management, and triaging skills; and an increased burden on trainees, including moral distress and decreased support from one another and other social supports. The COVID-19 pandemic has highlighted important opportunities in U.S. educational systems. As medical educators move forward, it will be important to learn from these while mitigating the negative impacts.

Experience of Parents of Children with Genetically Determined Leukoencephalopathies Regarding the Adapted Health Care Services During the COVID-19 Pandemic

Parents of children with genetically determined leukoencephalopathies play a major role in their children's health care. Because of the COVID-19 pandemic, many health care services were suspended, delayed or delivered remotely with telemedicine. We sought to explore the experience of parents of children with genetically determined leukoencephalopathies during the pandemic given the adapted health care services. We conducted semistructured interviews with 13 parents of 13 affected children. Three main themes were identified using thematic analysis: perceived impact of COVID-19 on health care services, benefits and challenges of telemedicine, and expectations of health care after the pandemic. Parents perceived a loss/delay in health care services while having a positive response to telemedicine. Parents wished telemedicine would remain in their care after the pandemic. This is the first study assessing the impact of COVID-19 on health care services in this population. Our results suggest that parents experience a higher level of stress owing to the shortage of services and the children's vulnerability.

Understanding Caregiving and Caregivers: Supporting Children and Youth With Special Health Care Needs at Home

Caregiving encompasses the nurturing, tasks, resources, and services that meet the day-to-day needs of children and youth with special health care needs (CYSHCN) at home. Many gaps exist in the strategies currently offered by the health care system to meet the caregiving needs of CYSHCN. The work of family caregivers of CYSHCN is known to be extensive, but it is so poorly understood that it has been described as "invisible". This invisibility leads to poor communication and gaps in understanding between professional health care providers and family caregivers. To address these gaps, health care researchers must work with family caregivers to incorporate their expertise on caregiving and create meaningful and sustainable research partnerships. A growing body of research is attempting to remedy the problem of caregiving invisibility and lay better foundations for successful integration between health care settings, family caregiving, professional caregiving, and community supports for families of CYSHCN. We identify high-priority gaps in CYSHCN caregiving research and propose research questions that are designed to accelerate growth in evidence-based understanding of the work of family caregivers of CYSHCN and how best to support them.

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics

In this article, we provide an overview of remote monitoring of pediatric PGHD and family-generated health data, including its current uses, future opportunities, and implementation resources.

Telemedicine in monitoring pediatric LT patients before and during COVID-19 pandemic

BACKGROUND

The delivery of healthcare services by telemedicine decreases costs of traveling for patients, is less time-consuming, and most importantly permits the connection between highly skilled specialists and patients. However, whether the use of telemedicine (text messaging) for LT patients was affected by the COVID-19 pandemic is unknown.

METHODS

We collected data (following consent from patients and parents) from 57 patients (33 male/24 female) with a median age of 47 (IQR: 9-91) months, whom we followed up with text messaging between September 2019 and September 2020, spanning the 6 months prior to COVID-19 and during this period.

RESULTS

In total, 723 text message mediated consultations occurred during this period, henceforth simply referred to as "messages." Three hundred and twenty-eight (45%) messages occurred during the 6 months up to the start of the pandemic. Following the COVID-19 outbreak, the number of messages increased to 395 (55%). The three most common reasons of messaging were post-liver-LT follow-up messages (n = 215/723, 29.7%), consultations for drug use (n = 157/723, 21.7%), and medication prescriptions (n = 113/723, 15.6%). Protocol biopsy discussions (n = 33/723, 4.6%) and fever (n = 27/723, 3.7%) were among others (vaccination, rash, diarrhea, cough, fatigue, acne). During the COVID-19 outbreak, only post-LT follow-up messages increased significantly to 132/395 (33%) from 83/328 (25%) (p-value: .02).

CONCLUSIONS

We found that the pandemic resulted in an increase in the total number of text message mediated consultations and specifically for the use of post-LT follow-up. Messaging was effective for post-LT follow-ups and all patients were at least satisfied.

Pediatric Tele-Home Care Compared to Usual Care: Cost-Minimization Analysis

BACKGROUND

Although home hospitalization has been a well-known and widespread practice for some time in the adult population, it has not been the same case in the pediatric setting. Simultaneously, telemedicine tools are a facilitator of the change in the health care model, which is increasingly focused on home care. In a pioneering way in Spain, the in-home hospitalization program of the Hospital Sant Joan de Déu in Barcelona allows the child to be in their home environment at the time they are being monitored and clinically followed by the professionals. Besides being the preferred option for families, previous experience suggests that pediatric home hospitalization reduces costs, primarily thanks to savings on the structural cost of the stay.

OBJECTIVE

The aim of this study is to compare the average cost of a discharge by tele-home care with the usual care and to analyze the main drivers of the differential costs of both care models.

METHODS

A cost-minimization analysis is conducted under a hospital's perspective, based on observational data, and estimated retrospectively. A historical control group of similar patients in terms of clinical casuistry to children hospitalized at home was used for comparison.

RESULTS

A 24-hour stay at the hospital costs US $574.19, while the in-home hospitalization costs US $301.71 per day, representing a saving of almost half (48%) of the cost compared to usual care. The main saving drivers were the personnel costs (US $102.83/US $284.53, 35.5% of the total), intermediate noncare costs (US $6.09/US $284.53, 33.17%), and structural costs (US $55.16/US $284.53, 19.04%). Home hospitalization involves a total stay 27.61% longer, but at almost half the daily cost, and thus represents a saving of US $176.70 (9.01%) per 24-hour stay.

CONCLUSIONS

The cost analysis conducted under a hospital perspective shows that pediatric tele-home care is 9% cheaper compared to regular hospital care. These results motivate the most widespread implementation of the service from the point of view of economic efficiency, adding to previous experiences that suggest that it is also preferable from the perspective of user satisfaction.

Parental Satisfaction from Telemedicine in the Follow-up of Children Operated for Craniosynostosis during COVID-19 Pandemic

OBJECTIVE

The current study aimed to evaluate the satisfaction level of parents from telemedicine use in the long-term follow-up of children operated for craniosynostosis during the COVID-19 pandemic.

DESIGN

A cross-sectional 9-question survey analysis using Qualtrics survey software.

SETTING

An institutional study carried out at a national, tertiary level academic center in the Slovak Republic.

PATIENTS

All patients operated for non-syndromic and syndromic craniosynostosis in our department, who participated in the virtual postoperative follow-up consultations from March 23, 2020, through July 2, 2021, were included in our series. They were enrolled 498 patients, with the parents of 256 children being responding to the survey.

INTERVENTIONS

The survey remained open until July 16, 2021, two weeks after the last virtual consultations. It was delivered to the parents by e-mail to generate closed 5-point Likert scale responses.

RESULTS

Overall, 72.3% of parents were satisfied with the telemedicine program, and 67.2% found it convenient. Collectively, 89.1% reported that the received instructions were helpful to them. However, only 18.7% of them answered that they would prefer telemedicine consultations in the future.

CONCLUSION

The results of this study showed a high satisfaction from the parents during the virtual follow-up of children operated for craniosynostosis. However, despite their positive experience with telemedicine, the vast majority of parents stated that they would prefer in-person visits in the future.

Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil

Background

Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs.

Methods

A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up.

Discussion

The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring.

Trial registration

NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.

Clinician Preferences for Current and Planned Future Use of Telemedicine

Introduction: Many clinicians and patients tried telemedicine for the first time during the COVID-19 pandemic. In a prior survey, we found that clinicians who were adaptable and willing to incorporate technology into their clinical practice are more likely to utilize telemedicine. Seeking factors associated with current and future use of telemedicine, and identifying its relative advantages and drawbacks, may help determine the role of telemedicine after the pandemic. Questions/Purposes: We asked (1) which demographic factors and personal preferences are associated with current and planned future use of telemedicine, (2) what factors are associated with telemedicine utilization, and (3) what are clinician-reported advantages and disadvantages of telemedicine? Materials and Methods: Approximately 750 clinicians within a national multispecialty hospital group were invited to complete an online survey assessing telemedicine use and preferences, self-reported technology proficiency, and personal characteristics. A total of 284 clinicians started the survey, and 259 complete responses were analyzed using bivariate analysis and multivariable regression. Results: More frequent current telemedicine use was associated with being a nonsurgeon clinician, not primarily practicing in an inpatient setting, preferring either telemedicine or having no preference for discussing sensitive topics, and greater self-reported technological proficiency. Planned future telemedicine use was associated with greater self-reported troubleshoot ability and less desire for a hands-on physical examination. Clinicians reported that the top benefits of telemedicine are decreased barriers for patients and convenience for clinicians, and disadvantages are technical difficulties for both patients and clinicians. Conclusions: Telemedicine continues to be widely utilized by clinicians, particularly those who are confident in their ability to examine patients over video, and who can troubleshoot issues that arise on the platform. With continued reimbursement, telemedicine is likely to remain a convenient and effective method of caring for patients.

Updated Review of the Pacific Asynchronous Telehealth System's Impact on Military Pediatric Teleconsultations

Introduction: The Pacific Asynchronous TeleHealth (PATH) system is an asynchronous provider-to-provider teleconsultation platform utilized by military medical facilities throughout the Western Pacific Region. This study focused on PATH utilization for pediatric cases and its impact on patient transfers and cost avoidance. Methods: This retrospective analysis reviewed PATH cases from March 2017 to February 2020 for patients aged 0-17 years. We reviewed the referring users' responses to survey questions related to the impact of PATH consultation on patient travel for in-person subspecialty care and the need for local referral. Data for cost avoidance were estimated using per diem rates and airline flight costs for Fiscal Year 2020. Results: A total of 2,448 pediatric consultations were submitted from 29 military medical facilities. Pediatric Pulmonology (n = 557, 24.5%), Pediatric Cardiology (n = 446, 19.6%), and Pediatric Neurology (n = 236, 10.37%) had the highest percentage of pediatric teleconsults. Approximately 42% of referring users completed the survey questions. Among survey respondents, 710 (69.4%) indicated that unnecessary patient transfers were prevented, equating to a cost savings of ∼$3.3 million. Conclusions: We observed robust utilization of the PATH system by pediatric providers in the Military Health System that ultimately resulted in substantial cost avoidance. This asynchronous telemedicine platform is a vital asset in locations with limited access or travel restriction to medical specialists, such as during pandemics.