Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review

Rurality, Death, and Healthcare Utilization in Heart Failure in the Community

Background Prior reports indicate that living in a rural area may be associated with worse health outcomes. However, data on rurality and heart failure (HF) outcomes are scarce. Methods and Results Residents from 6 southeastern Minnesota counties with a first-ever code for HF (International Classification of Diseases, Ninth Revision [ICD-9], code 428, and International Classification of Diseases, Tenth Revision [ICD-10] code I50) between January 1, 2013 and December 31, 2016, were identified. Resident address was classified according to the rural-urban commuting area codes. Rurality was defined as living in a nonmetropolitan area. Cox regression was used to analyze the association between living in a rural versus urban area and death; Andersen-Gill models were used for hospitalization and emergency department visits. Among 6003 patients with HF (mean age 74 years, 48% women), 43% lived in a rural area. Rural patients were older and had a lower educational attainment and less comorbidity compared with patients living in urban areas (P<0.001). After a mean (SD) follow-up of 2.8 (1.7) years, 2440 deaths, 20 506 emergency department visits, and 11 311 hospitalizations occurred. After adjustment, rurality was independently associated with an increased risk of death (hazard ratio [HR], 1.18; 95% CI, 1.09-1.29) and a reduced risk of emergency department visits (HR, 0.89; 95% CI, 0.82-0.97) and hospitalizations (HR, 0.78; 95% CI, 0.73-0.84). Conclusions Among patients with HF, living in a rural area is associated with an increased risk of death and fewer emergency department visits and hospitalizations. Further study to identify and address the mechanisms through which rural residence influences mortality and healthcare utilization in HF is needed in order to reduce disparities in rural health.

Feasibility and acceptability of a technology-based, rural weight management intervention in older adults with obesity

BACKGROUND

Older adults with obesity residing in rural areas have reduced access to weight management programs. We determined the feasibility, acceptability and preliminary outcomes of an integrated technology-based health promotion intervention in rural-living, older adults using remote monitoring and synchronous video-based technology.

METHODS

A 6-month, non-randomized, non-blinded, single-arm study was conducted from October 2018 to May 2020 at a community-based aging center of adults aged ≥65 years with a body mass index (BMI) ≥30 kg/m2. Weekly dietitian visits focusing on behavior therapy and caloric restriction and twice-weekly physical therapist-led group strength, flexibility and balance training classes were delivered using video-conferencing to participants in their homes. Participants used a Fitbit Alta HR for remote monitoring with data feedback provided by the interventionists. An aerobic activity prescription was provided and monitored.

RESULTS

Mean age was 72.9±3.9 years (82% female). Baseline anthropometric measures of weight, BMI, and waist circumference were 97.8±16.3 kg, 36.5±5.2 kg/m2, and 115.5±13.0 cm, respectively. A total of 142 participants were screened (n=27 ineligible), and 53 consented. There were nine dropouts (17%). Overall satisfaction with the trial (4.7+ 0.6, scale: 1 (low) to 5 (high)) and with Fitbit (4.2+ 0.9) were high. Fitbit was worn an average of 81.7±19.3% of intervention days. In completers, mean weight loss was 4.6±3.5 kg or 4.7±3.5% (p< 0.001). Physical function measures of 30-s sit-to-stand repetitions increased from 13.5±5.7 to 16.7±5.9 (p< 0.001), 6-min walk improved by 42.0±77.3 m (p=0.005) but no differences were observed in gait speed or grip strength. Subjective measures of late-life function improved (3.4±4.7 points, p< 0.001).

CONCLUSIONS

A technology-based obesity intervention is feasible and acceptable to older adults with obesity and may lead to weight loss and improved physical function.

CLINICAL TRIAL REGISTRATION

Registered on Clinicaltrials.gov # NCT03104205 . Registered on April 7, 2017. First participant enrolled on October 1st, 2018.

Blended home-based exercise and dietary protein in community-dwelling older adults: a cluster randomized controlled trial

BACKGROUND

Effective and sustainable interventions are needed to counteract the decline in physical function and sarcopenia in the growing aging population. The aim of this study was to determine the 6 and 12 month effectiveness of blended (e-health + coaching) home-based exercise and a dietary protein intervention on physical performance in community-dwelling older adults.

METHODS

This cluster randomized controlled trial allocated 45 clusters of older adults already engaged in a weekly community-based exercise programme. The clusters were randomized to three groups with ratio of 16:15:14; (i) no intervention, control (CON); (ii) blended home-based exercise intervention (HBex); and (iii) HBex with dietary protein counselling (HBex-Pro). Both interventions used a tablet PC with app and personalized coaching and were targeting on behaviour change. The study comprised coached 6 month interventions with a 6 month follow-up. The primary outcome physical performance was assessed by modified Physical Performance Test (m-PPT). Secondary outcomes were gait speed, physical activity level (PAL), handgrip muscle strength, protein intake, skeletal muscle mass, health status, and executive functioning. Linear mixed models of repeated measured were used to assess intervention effects at 6 and 12 months.

RESULTS

The population included 245 older adults (mean age 72 ± 6.5 (SD) years), 71% female, and 54% co-morbidities observed. Dropout of the intervention was 18% at 6 months and 26% at 12 months. Participants were well functioning, based on an m-PPT score of 33.9 (2.8) out of 36. For the primary outcome m-PPT, no significant intervention effects (HBex, +0.03, P = 0.933; HBex-Pro, -0.13, P = 0.730) were found. Gait speed (+0.20 m/s, P = 0.001), PAL (+0.06, P = 0.008), muscle strength (+2.32 kg, P = 0.001), protein intake (+0.32 g/kg/day, P < 0.001), and muscle mass (+0.33 kg, P = 0.017) improved significantly in the HBex-Pro group compared with control group after 6 month intervention. The protein intake, muscle mass, and strength remained significantly improved after 12 months as compared with those of control. Health change and executive functioning improved significantly in both intervention groups after 6 months.

CONCLUSIONS

This HBex and dietary protein interventions did not change the physical performance (m-PPT) in community-dwelling older adults. Changes were observed in gait speed, PAL, muscle mass, strength, and dietary protein intake, in response to this combined intervention.

Analysis of Feasibility, Adherence, and Appreciation of a Newly Developed Tele-Rehabilitation Program for People With MCI and VCI

Background: Patients with Mild Cognitive Impairment (MCI) and Vascular Cognitive Impairment (VCI) are at a high risk of progressing to dementia. Recent guidelines indicate the importance of promoting multidimensional and multi-domain interventions to prevent further decline. Due to its growing effectiveness, comparable to conventional face-to-face interventions, the use of technology is gaining relevance. Tele-rehabilitation systems have the potential to engage patients in multi-dimensional activity programs and to guarantee a low-cost continuum of care through remote control. A possible limitation of such programs is represented by the lack of familiarization with technology and computers in elderly people. The purpose of this study is to describe the feasibility, adherence, and appreciation of the GOAL Tele-R system, administered by a web-application through remote control in patients with MCI/VCI. Methods: Feasibility of the Tele-R system was evaluated by means of distribution of patients' attrition along the study phases, controlling for potential systematic bias in drop-out rates due to the technological device. Adherence was evaluated analyzing drop-out rates and indexes of carried out activities. Patients' appreciation was analyzed through ad hoc satisfaction questionnaire items. Results: Out of 86 approached patients, 25 (29%) were not enrolled, 30 (35%) dropped-out after randomization, and 31 (36%) completed the study (standard care group n = 12, the tele-R group n = 19). Compared to the tele-R group, rates of drop-outs resulted significantly higher for the standard care group (34 vs. 62%, respectively, p = 0.029). Taking into account baseline characteristics, females resulted in a statistically significant higher rate of drop-outs compared to males (66 vs. 27%, respectively, p = 0.003). Overall adherence to the proposed activities was 84% (85% for cognitive module and 83% for physical activity module). Concerning satisfaction, participants provided a good mean level of appreciation (3.7 ± 0.8, range 1-5), a positive feedback for usability, and a subjective perception of cognitive, emotional, and physical benefits due to the training. Conclusion: The GOAL Tele-R system seems a feasible technological rehabilitation program, reaching an acceptable level of adherence and appreciation in patients with an MCI/VCI condition. Clinical Trial Registration: www.ClinicalTrials.gov, ID: NCT03383549 (registration date: 26/dec/2017).

Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis

BACKGROUND

Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care.

OBJECTIVE

This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics.

METHODS

We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation.

RESULTS

Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively).

CONCLUSIONS

Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.

Effective remote staff training of objective session notes

Session notes are a required component of documenting behavior analytic sessions. The direct training of writing objective session notes is important to the success of direct line staff completing adequate documentation and meeting requirements set forth by agencies, certification boards, and insurance funders. However, in-person training is not always immediately available due to contextual restrictions. This study evaluated the effectiveness of implementing the teaching interaction procedure when training staff remotely to objectively document client progress within session notes. Three Registered Behavior Technicians™ (RBT®s) were trained via telehealth to complete session notes objectively. Results showed that all 3 participants met the mastery criterion during probes measuring the objective documentation of home-based behavior analytic sessions. These findings suggest that a training package, such as the teaching interaction procedure, can be effectively implemented remotely when conducting staff training.

Monitoring of COVID-19 patients by telemedicine with telemonitoring

AIM

To asses if telemedicine with telemonitoring is a clinically useful and secure tool in the tracking of patients with COVID-19.

METHODS

A prospective observational study of patients with COVID-19 diagnosis by positive PCR considered high-risk tracked with telemedicine and telemonitoring was conducted in the sanitary area of Lugo between March 17th and April 17th, 2020. Two groups of patients were included: Outpatient Tracing from the beginning and after discharge. Every patient sent a daily clinical questionnaire with temperature and oxygen saturation 3 times a day. Proactive monitoring was done by getting in touch with every patient at least 11a day.

RESULTS

313 patients (52.4% female) with a total average age of 60.9 (DE 15.9) years were included. Additionally, 2 patients refused to join the program. Since the beginning, 224 were traced outpatient and 89 after being discharged. Among the first category, 38 (16.90%) were referred to Emergency department on 43 occasions; 18 were hospitalized (8.03%), and 2 deceased. Neither deaths nor a matter of vital emergency occurred at home. When including patients after admissions monitoring was done in 304 cases. One patient re-entered (0.32%) to the hospital, and another one left the program (0.32%). The average time of monitoring was 11.64 (SD 3.58) days, and 224 (73.68%) patients were discharged during the 30 days of study.

CONCLUSIONS

Our study suggests that telemedicine with home telemonitoring, used proactively, allows for monitoring high-risk patients with COVID-19 in a clinically useful and secure way.

Monitoring of COVID-19 patients via telemedicine with telemonitoring

Aim

To asses if telemedicine with telemonitoring is a clinically useful and safe tool for monitoring patients with COVID-19.

Methods

A prospective observational study of patients with COVID-19 diagnosed via a positive PCR test who were considered high-risk and who were monitored with telemedicine and telemonitoring in the Lugo Healthcare Area between March 17th and April 17th, 2020, was conducted. Two groups of patients were included: those in outpatient monitoring from the beginning and those in outpatient monitoring following hospital discharge. Every patient completed a clinical questionnaire with his or her temperature once per day and oxygen saturation levels three times per day. Proactive monitoring was done by getting in touch with every patient at least once a day.

Results

A total of 313 patients (52.4% female) with a mean age of 60.9 (SD 15.9) years were included. Two patients refused to participate in the program. Finally, 224 were monitored from the beginning and 89 patients were monitored after discharged. In the first group, 38 (16.90%) were referred to the Emergency department on 43 occasions; 18 (8.03%) were hospitalized, and two died. There were no deaths or lifethreatening at home. Including the patients monitored after hospitalization, monitoring was performed in 304 cases. One patient was readmited (0.32%) and another left the program (0.32%). The mean time of monitoring was 11.64 (SD 3.58) days and 224 (73.68%) patients were discharged during the 30 days the study lasted.

Conclusions

Our data suggest that telemedicine with at-home telemonitoring, when used proactively, allows for clinically useful and safe monitoring of high-risk patients with COVID-19.

An overview of reviews on strategies to reduce health inequalities

BACKGROUND

Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions.

OBJECTIVE

Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities.

METHODS

A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in "Effective Practice and Organization of Care". The quality of the included LRs was evaluated using the AMSTAR 2 tool.

RESULTS

Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes.

CONCLUSION

The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.

Technology and Specialist Care for Older Patients in the Post Covid-19 Era

The COVID-19 pandemic poses a major challenge to delivering multi-disciplinary complex care for older patients. Modern technology can assist in providing such care. This article highlights efforts to bridge the "digital divide" between generations and addresses the beneficial impact telemedicine has on older people's lifestyles. Novel triage models for accessing emergency care which were successful for patients of all age groups including those over 65 years are described. Moreover, innovative successful approaches to the outpatient assessment of older patients with complex chronic health conditions using telemedicine are highlighted. Furthermore, innovative solutions piloted in remote areas of Australia offer promise for telemedicine-lead remote assessment of older patients, and the results are encouraging compared to in-person consultations. The experience with a General Practitioner (GP)/specialist online real-time interaction model for remote management of HF in mainly older people has also been encouraging. The use of telemedicine in falls prevention has produced impressive results in high-risk older patients albeit with some ambivalence from older participants. Virtual reality rehabilitation programmes have produced better physical outcomes than traditional rehabilitation programmes. Furthermore, telerehabilitation for chronic obstructive pulmonary disease (COPD) and HF have shown to be both feasible and effective. To maximise their benefits in the difficult post-COVID-19 period, technologies must be embraced by both physicians and older patients. Online community care platforms discussed have demonstrated a positive, tangible impact on the lifestyle of the older generation. Furthermore, educational guidelines can assist in implementing the fundamentals of telemedicine, but for the widespread successful and safe integration of these services, adoption of regulatory frameworks with a focus on ethical issues of telehealth is imperative.

Disparities in use of telehealth at the onset of the COVID-19 public health emergency

Introduction

The coronavirus disease 2019 (COVID-19) pandemic resulted in an unprecedented expansion in telehealth, but little is known about differential use of telehealth according to demographics, rurality, or insurance status.

Methods

We performed a cross-sectional analysis of 7742 family medicine encounters at a single USA institution in the initial month of the COVID-19 public health emergency (PHE). We compared the demographics of those using telehealth during the PHE to those with face-to-face visits during the same time period; we also compared the demographics of those using full audio-video to those using audio-only.

Results

The likelihood of any telehealth visit in the first 30 days of telehealth expansion was higher for women, those age 65 years and older, self-pay patients, and those with Medicaid and Medicare as primary payers. The likelihood of a telehealth visit was reduced for rural residence and Black or other races. Among all telehealth visits, the likelihood of a full audio-video telehealth visit was reduced for patients who were older, Black, from urban areas, or who were self-pay, Medicaid, or Medicare payer status.

Discussion

Significant disparities exist in telehealth use during the COVID-19 PHE by age, race, residence and payer.

Rapid Integration of Home Telehealth Visits Amidst COVID-19: What Do Older Adults Need to Succeed?

OBJECTIVE

Our objective was to identify and address patient-perceived barriers to integrating home telehealth visits.

DESIGN

We used an exploratory sequential mixed-methods design to conduct patient needs assessments, a home telehealth pilot, and formative evaluation of the pilot.

SETTING

Veterans Affairs geriatrics-renal clinic.

PARTICIPANTS

Patients with scheduled clinic visits from October 2019 to April 2020.

MEASUREMENTS

We conducted an in-person needs assessment and telephone postvisit interviews.

RESULTS

Through 50 needs assessments, we identified patient-perceived barriers in interest, access to care, access to technology, and confidence. A total of 34 (68%) patients were interested in completing a home telehealth visit, but fewer (32 (64%)) had access to the necessary technology or were confident (21 (42%)) that they could participate. We categorized patients into four phenotypes based on their interest and capability to complete a home telehealth visit: interested and capable, interested and incapable, uninterested and capable, and uninterested and incapable. These phenotypes allowed us to create trainings to overcome patient-perceived barriers. We completed 32 home telehealth visits and 12 postvisit interviews. Our formative evaluation showed that our pilot was successful in addressing many patient-perceived barriers. All interviewees reported that the home telehealth visits improved their well-being. Home telehealth visits saved participants an average of 166 minutes of commute time. Five participants borrowed a device from a family member, and five visits were finished via telephone. All participants successfully completed a home telehealth visit.

CONCLUSIONS

We identified patient-perceived barriers to home telehealth visits and classified patients into four phenotypes based on these barriers. Using principles of implementation science, our home telehealth pilot addressed these barriers, and all patients successfully completed a visit. Future study is needed to understand methods to deploy larger-scale efforts to integrate home telehealth visits into the care of older adults.

Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19

The use of remote health care services, or telehealth, is a promising solution for providing health care to those unable to access care in person easily and thus helping to reduce health inequalities. The COVID-19 pandemic and resulting stay-at-home orders in the United States have created an optimal situation for the use of telehealth services for non-life-threatening health care use. A retrospective cohort study was performed using Kantar's Claritis™ database, which links insurance claims encounters (Komodo Health) with patient-reported data (Kantar Health, National Health & Wellness Survey). Logistic regression models (odds ratios [OR], 95% confidence intervals [CI]) examined predictors of telehealth versus in-person encounters. Adults ages ≥18 years eligible for payer-complete health care encounters in both March 2019 and March 2020 were identified (n = 35,376). Telehealth use increased from 0.2% in 2019 to 1.9% in 2020. In adjusted models of respondents with ≥1 health care encounter (n = 11,614), age, marital status, geographic residence (region; urban/rural), and presence of anxiety or depression were significant predictors of telehealth compared with in-person use in March 2020. For example, adults 45-46 years versus 18-44 years were less likely to use telehealth (OR 0.684, 95% CI: 0.561-0.834), and respondents living in urban versus rural areas were more likely to use telehealth (OR 1.543, 95% CI: 1.153-2.067). Substantial increases in telehealth use were observed during the onset of the COVID-19 pandemic in the United States; however, disparities existed. These inequalities represent the baseline landscape that population health management must monitor and address during this pandemic.

Pharmacist-Led Chronic Care Management for Medically Underserved Rural Populations in Florida During the COVID-19 Pandemic

Medically underserved patients in rural areas are more vulnerable to poor health outcomes, including the risks associated with coronavirus disease 2019 (COVID-19). Pharmacists, student pharmacists, and other health care professionals are working together to implement new, innovative ways to deliver the same standard of care during the COVID-19 pandemic to these vulnerable patients. These services include telehealth with virtual and telephone medication therapy management sessions led by ambulatory care pharmacists and student pharmacists. Pharmacists, student pharmacists, and other health care professionals should continue to adapt to these new technologies to improve health outcomes for their patients during the pandemic.

Feasibility of Perioperative eHealth Interventions for Older Surgical Patients: A Systematic Review

OBJECTIVES

EHealth interventions are increasingly being applied in perioperative care but have not been adequately studied for older surgical patients who could potentially benefit from them. Therefore, we evaluated the feasibility of perioperative eHealth interventions for this population.

DESIGN

A systematic review of prospective observational and interventional studies was conducted. Three electronic databases (PubMed, EMBASE, CINAHL) were searched between January 1999 and July 2019. Study quality was assessed by Methodological Index for Non-Randomized Studies (MINORS) with and without control group.

SETTING AND PARTICIPANTS

Studies of surgical patients with an average age ≥65 years undergoing any perioperative eHealth intervention with active patient participation (with the exception of telerehabilitation following orthopedic surgery) were included.

MEASURES

The main outcome measure was feasibility, defined as a patient's perceptions of usability, satisfaction, and/or acceptability of the intervention. Other outcomes included compliance and study completion rate.

RESULTS

Screening of 1569 titles and abstracts yielded 7 single-center prospective studies with 223 patients (range n = 9-69 per study, average age 66-74 years) undergoing oncological, cardiovascular, or orthopedic surgery. The median MINORS scores were 13.5 of 16 for 6 studies without control group, and 14 of 24 for 1 study with a control group. Telemonitoring interventions were rated as "easy to use" by 89% to 95% of participants in 3 studies. Patients in 3 studies were satisfied with the eHealth intervention and would recommend it to others. Acceptability (derived from consent rate) ranged from 71% to 89%, compliance from 53% to 86%, and completion of study follow-up from 54% to 95%.

CONCLUSIONS AND IMPLICATIONS

Results of 7 studies involving perioperative eHealth interventions suggest their feasibility and encourage further development of technologies for older surgical patients. Future feasibility studies require clear definitions of appropriate feasibility outcome measures and a comprehensive description of patient characteristics such as functional performance, level of education, and socioeconomic status.

Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians

Importance

Video or telephone telemedicine can offer patients access to a clinician without arranging for transportation or spending time in a waiting room, but little is known about patient characteristics associated with choosing between telemedicine or office visits.

Objective

To examine patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians.

Design, Setting, and Participants

This cross-sectional study included data from 1 131 722 patients who scheduled a primary care appointment through the Kaiser Permanente Northern California patient portal between January 1, 2016, and May 31, 2018. All completed primary care appointments booked via the patient portal were identified. Only index visits without any other clinical visits within 7 days were included to define a relatively distinct patient-initiated care-seeking episode. Visits for routine physical, which are not telemedicine-eligible, were excluded. Data were analyzed from July 1, 2018, to December 31, 2019.

Main Outcomes and Measures

Patient choice between an office, video, or telephone visit. Relative risk ratios (RRRs) for patient sociodemographic characteristics (age, sex, race/ethnicity, neighborhood socioeconomic status, language preference), technology access (neighborhood residential internet, mobile portal use), visiting the patient's own personal primary care clinician, and in-person visit barriers (travel-time, parking, cost-sharing), associated with choice of video or telephone telemedicine (vs office visit).

Results

Of 2 178 440 patient-scheduled primary care visits scheduled by 1 131 722 patients, 86% were scheduled as office visits and 14% as telemedicine visits, with 7% of the telemedicine visits by video. Choosing telemedicine was statistically significantly associated with patient sociodemographic characteristics. For example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine (RRR, 0.24; 95% CI, 0.22-0.26 for video visit; RRR 0.55; 95% CI, 0.54-0.57 for telephone visit). Choosing telemedicine was also statistically significantly associated with technology access (patients living in a neighborhood with high rates of residential internet access were more likely to choose a video visit than patients whose neighborhoods had low internet access: RRR, 1.10; 95% CI, 1.06-1.14); as well as in-person visit barriers (patients whose clinic had a paid parking structure were more likely to choose a telemedicine visit than patients whose facility had free parking: RRR, 1.70; 95% CI, 1.41-2.05 for video visit; and RRR, 1.73, 95% CI, 1.61-1.86 for telephone visit).

Conclusions and Relevance

In this cross-sectional study, patients usually chose an in-person visit when scheduling an appointment online through the portal. Telemedicine may offer the potential to reach vulnerable patient groups and improve access for patients with transportation, parking, or cost barriers to clinic visits.

Using virtual worlds as a platform for collaborative meetings in healthcare: a feasibility study

BACKGROUND

Healthcare teams often consist of geographically dispersed members. Virtual worlds can support immersive, high-quality, multimedia interaction between remote individuals; this study investigated use of virtual worlds to support remote healthcare quality improvement team meetings.

METHODS

Twenty individuals (12 female, aged 25-67 [M = 42.3, SD = 11.8]) from 6 healthcare quality improvement teams conducted collaborative tasks in virtual world or face-to-face settings. Quality of collaborative task performances were measured and questionnaires and interviews were used to record participants' experiences of conducting the tasks and using the virtual world software.

RESULTS

Quality of collaborative task outcomes was high in both face-to-face and virtual world settings. Participant interviews elicited advantages for using virtual worlds in healthcare settings, including the ability of the virtual environment to support tools that cannot be represented in equivalent face-to-face meetings, and the potential for virtual world settings to cause improvements in group-dynamics. Reported disadvantages for future virtual world use in healthcare included the difficulty that people with weaker computer skills may experience with using the software. Participants tended to feel absorbed in the collaborative task they conducted within the virtual world, but did not experience the virtual environment as being 'real'.

CONCLUSIONS

Virtual worlds can provide an effective platform for collaborative meetings in healthcare quality improvement, but provision of support to those with weaker computer skills should be ensured, as should the technical reliability of the virtual world being used. Future research could investigate use of virtual worlds in other healthcare settings.

Telehealth monitoring of a hypertensive elderly patient with the new VITASENIOR-MT system: a case study

Telehealth technologies providing remote monitoring of health parameters are a promising approach for the management of arterial hypertension in the elderly. The VITASENIOR-MT platform was developed as a telehealth solution designed to contribute to improve the health condition and quality of life, promoting safe and independent living of the old adult. It is an 'internet-of-things'-based solution relying on the interaction of the old adult with a TV-set to record biometric parameters and to receive warning and recommendations related to health and environmental sensor recordings. We present a pilot study with a male hypertensive patient, aged 81 years old, under anti-hypertensive treatment, with epilepsy, arthritis and paroxistic atrial fibrillation as major comorbidities. The VITASENIOR-MT was installed at the patient's assisted-dwelling house and a remote follow-up was implemented for 2 months, monitoring daily blood pressure and heart rate, as well as weight and indoor environmental parameters.

The Influence of Telemedicine Care on the Management of Behavioral and Psychological Symptoms in Dementia (BPSD) Risk Factors Induced or Exacerbated During the COVID-19 Pandemic

The number of people with dementia worldwide is expected to increase to approximately 1.3 billion in 2050. Almost 90% of patients diagnosed with dementia suffer from behavioral and psychological symptoms of dementia (BPSD). BPSD causes and risk factors are multiple and complex and can be responsible for hospitalizations in long-term institutions, psychiatric hospitalizations and search for health services. Recently, the world imposition of social distance and self-isolation as the best preventive measures for the COVID-19 pandemic has created challenges in the health care and management of this population, which may trigger or aggravate BPSD, and most caregivers are not prepared to address it. In face of this actual social distancing, telemedicine comes to be a tool for improving the management of these acute symptoms and mental care. In this article, we discuss and disseminate recommendations on this important alternative of assistance, especially considering the cases of BPSD. In this context of a pandemic, even patients with BPSD and caregivers require more frequent and updated guidance, considering the difficult context to social distance. Telemedicine can reduce the risk for the development of negative outcomes in mental health precipitated by the reduction of social contact and less access to health services, improving dementia symptom management, mainly BPSD.

Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Background

Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain.

Objective

This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care.

Methods

A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis.

Results

This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes.

Conclusions

E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

Improving geriatric care and reducing hospitalisations in regional and remote areas: The benefits of telehealth

INTRODUCTION

The aim of this study was to compare the effectiveness of two geriatrician models of care, the telegeriatric service (TGS) and visiting geriatrician (VG), in regional and remote settings in terms of potential cost-savings to the health system and impact on health service use (HSU). Furthermore, to establish whether longer wait-times for clinic appointments led to increased HSU by study participants.

METHODS

Trends in patient emergency department presentations, hospitalisations and bed-days (HSU) were compared from 18 months before to 12 months after geriatrician appointment for the two services in the Western Australian Midwest region. The relationships between wait times, patient triage level and HSU were modelled. The costs of providing the services were offset against reductions in HSU after appointments.

RESULTS

The sample comprised consecutive patients using the TGS (n = 84) and VG service (n = 124). Patient characteristics were similar, although patients using the VG service had longer wait-times, were triaged as more urgent and demonstrated the highest levels of HSU. Both models were effective with similar rates of reduced HSU following appointments. Increased wait-times and higher patient triage urgency were associated with increased HSU.

DISCUSSION

Although TGS and VG showed similar reduced rates of HSU, TGS had the capacity to see a higher volume of patients, a broader geographical reach and improved waitlist management. Consequently, TGS was more effective at reducing avoidable hospitalisations and subsequent health deterioration due to shorter wait-times. Whilst face-to-face consultations are recognised as 'gold standard' a combination of the two models is most efficient.