Cost analysis of a speech pathology synchronous telepractice service for patients with head and neck cancer

Models of survivorship care in patients with head and neck cancer in regional, rural, and remote areas: a systematic review

PURPOSE

Rural people with head and neck cancers (HNC) are likely to experience poorer health outcomes due to limited access to health services, so many benefit from models of care that account for rurality. The aim of this review was to synthesise literature on models of care in this population.

METHODS

Studies were identified using seven databases: PubMed, PsycINFO, Scopus, Embase, CINAHL, Medline, and Web of Science. Studies that tested or reported a model of care in rural HNC survivors were included. Data on characteristics and outcomes of the models were synthesised according to the domains in the Cancer Survivorship Care Quality Framework, and study quality was appraised.

RESULTS

Seventeen articles were included. Eight were randomised controlled trials (seven with a control group and one single-arm study). Three models were delivered online, nine via telehealth, and five in-person. Majority were led by nurses and allied health specialists and most addressed management of physical (n = 9) and psychosocial effects (n = 6), while only a few assessed implementation outcomes such as cost-effectiveness. None evaluated the management of chronic health conditions.

CONCLUSION

Positive outcomes were reported for domains of survivorship care that were measured; however, further evaluation of models of care for rural people with HNC is needed to assess effectiveness across all domains of care.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors are a diverse population with unique needs. Alternative models of care such as shared care, or models personalised to the individual, could be considered to reduce disparities in access to care and outcomes.

Normative Values of Client-Reported Outcome Measures and Self-Ratings of Six Voice Parameters via the VoiceEvalU8 App

OBJECTIVES

Ecological momentary assessments (EMA) and interventions (EMI) have the potential to assess and offer interventions repeatedly within the client's daily life through mobile app technology. Considering the development of the EMA VoiceEvalU8, the current work provided normative data by comparing traditional (i.e., paper and pencil) and electronic (i.e., VoiceEvalU8 app) administration modalities of client-reported outcome measures and client self-ratings of six voice parameters twice a day in their functional environment.

METHODS

In Experiment 1, 50 vocally healthy cisgender women and men completed the Voice Handicap Index (VHI)-30, VHI-10, and Vocal Fatigue Index (VFI) with paper and pencil and the VoiceEvalU8 app. The order of administration modality and perceptual scales was randomized for each participant. In Experiment 2, 104 vocally healthy cisgender women and men used the VoiceEvalU8 app across five days in the morning before talking all day and in the evening after talking all day to self-rate six voice parameters (i.e., overall quality, roughness, breathiness, strain, pitch, and loudness) on a scale from 0 - 100. Mann Whitney U tests were run for all measures. Means and standard deviations are reported for descriptive analysis and normative values.

RESULTS

In Experiment 1, results showed no significant differences between paper and pencil and VoiceEValU8 app administration for the VHI-30, VHI-10, and VFI for vocally healthy adults. Normative values in the current study were consistent with previous literature for the VHI-10 and VFI factor 1 and 2, but slightly higher for the VHI-30 and slightly lower for the VFI factor 3. In Experiment 2, results demonstrated significant differences for all six voice parameters between the morning and evening log sessions. Normative values demonstrated higher self-ratings in the morning as compared to the evening.

CONCLUSIONS

For vocally healthy adults, completing the VHI-30, VHI-10, and VFI via paper and pencil and the VoiceEvalU8 app yielded the same results. Client self-ratings of six voice parameters on a scale from 0 - 100 twice a day demonstrated that vocally healthy adults perceived voice to be worse in the morning before talking all day as compared to the evening after talking all day. The results from the current work are promising for EMA via the VoiceEvalU8 app and support the need for continued investigations with clients with voice differences, problems, and/or disorders.

Systems archetypes to investigate the unintended consequences of telehealth in rural Australia: A systems thinking approach to telehealth evaluation and policymaking

As an alternative model of delivery to standard care, telehealth offers a promising solution to health access issues faced by rural and remote communities in Australia and worldwide. However, research typically focuses on its expected benefits and pitfalls, with little to no consideration of its unintended consequences and factors influencing its better utilisation. Drawing on systems thinking and informed by complexity science, we propose using systems archetypes-systems thinking tools - as a magnifying lens to investigate potential telehealth unintended consequences or outcomes. We conceptualise telehealth implementation in rural and remote Australia as a sociotechnical system whereby the interactions between its various agents shape telehealth implementation and, in turn, are shaped by it. When introducing new policies or interventions to any system, these interactions often lead to outcomes other than those initially planned or intended. Although systems archetypes cannot necessarily predict these outcomes, they are valuable for helping anticipate unintended, unforeseen outcomes and facilitating discussions about them to mitigate their negative impact and maximise their benefits. Outcomes are not necessarily adverse; they can also be positive. So, investigating such outcomes will minimise their negative impact and maximise their benefit. Our method was to review existing research and a selection of complexity and systems informed frameworks. Then, we assessed systems archetypes. And how they can be utilised to investigate unintended consequences. A worked example of what an unintended consequence in the implementation of telehealth in rural and remote Australia is presented.

Challenges and opportunities of tele-speech therapy: Before and during the COVID-19 pandemic

In 2020, with the onset of the COVID-19 pandemic, the treatment and rehabilitation process faced problems and challenges. One of the most efficient therapy approaches in this period was telerehabilitation. Telepractice in speech therapy presents many challenges and opportunities. In this article, we review published articles up to June 2023 and summarize the challenges and opportunities of the COVID-19 pandemic for speech therapy. Researchers and clinicians have found that tele-speech therapy is an effective tool for improving access to high-quality services and a viable mechanism for delivering speech and language interventions. The results of teletherapy or telepractice during the COVID-19 pandemic were divided into opportunities and challenges. Speech therapy has moved toward telerehabilitation to improve treatment competence during the pandemic. Finally, teletherapy methods were more suitable for speech and language pathology.

The influence of telehealth-based cancer rehabilitation interventions on disability: a systematic review

PURPOSE

To characterize delivery features and explore effectiveness of telehealth-based cancer rehabilitation interventions that address disability in adult cancer survivors.

METHODS

A systematic review of electronic databases (CINAHL Plus, Cochrane Library: Database of Systematic Reviews, Embase, National Health Service's Health Technology Assessment, PubMed, Scopus, Web of Science) was conducted in December 2019 and updated in April 2021.

RESULTS

Searches identified 3,499 unique studies. Sixty-eight studies met inclusion criteria. There were 81 unique interventions across included studies. Interventions were primarily delivered post-treatment and lasted an average of 16.5 weeks (SD = 13.1). They were most frequently delivered using telephone calls (59%), administered delivered by nursing professionals (35%), and delivered in a one-on-one format (88%). Risk of bias of included studies was primarily moderate to high. Included studies captured 55 measures of disability. Only 54% of reported outcomes had data that allowed calculation of effect sizes ranging -3.58 to 15.66.

CONCLUSIONS

The analyses suggest small effects of telehealth-based cancer interventions on disability, though the heterogeneity seen in the measurement of disability makes it hard to draw firm conclusions. Further research using more diverse samples, common measures of disability, and pragmatic study designs is needed to advance telehealth in cancer rehabilitation.

IMPLICATIONS FOR CANCER SURVIVORS

Telehealth-based cancer rehabilitation interventions have the potential to increase access to care designed to reduce disability across the cancer care continuum.

Efficacy of Aphasia Group Conversation Treatment via Telepractice on Language and Patient-Reported Outcome Measures

PURPOSE

Conversation treatment for people with aphasia (PwA) can lead to significant changes in language impairment and quality of life. The COVID-19 pandemic has resulted in the greater use of telepractice treatment delivery. However, there is little evidence regarding the efficacy of telepractice conversation groups. This study investigated the effects of telepractice group conversation treatment on standardized measures of language function and socially oriented/patient-reported outcomes compared to in-person and no-treatment control data.

METHOD

This study used a mixed within- and between-groups design (repeated measure/pre-post treatment), with a single-subject delayed treatment design (Shadish & Rindskopf, 2007) to establish baseline, pretreatment, and posttreatment periods for the telepractice group. Telepractice results pre- and posttreatment were compared with historical in-person and no-treatment control data obtained from a larger randomized control trial (RCT) from DeDe et al. (2019). The historical comparison data were a subset of RCT participants from the same location and included six in-person participants and seven no-treatment control group participants.

RESULTS

Results of standardized testing conducted at baseline, pretreatment, and posttreatment intervals revealed significant improvement from pre- to posttreatment on repetition and picture description tasks for the telepractice group, and significant improvement from pre- to posttreatment on the Aphasia Communication Outcome Measure, total number of relevant utterances, and percentage of complete utterances for the in-person conversation group. No significant differences were observed in the no-treatment groups.

CONCLUSIONS

In contrast to the no-treatment condition, both the in-person and telepractice conditions showed the benefits of conversation group treatment. The in-person treatment condition showed improvements in a wider number of outcome measures than the telepractice condition. Overall, the results prompt further research regarding telepractice group conversation treatment for PwA.

A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice

INTRODUCTION

Telepractice models of care have the potential to reduce the time and financial burdens that consumers may experience accessing healthcare services. The current study aimed to conduct a time and financial cost analysis of paediatric feeding appointments accessed via telepractice (using videoconferencing) compared to an in-person model.

METHODS

Parents of 44 children with paediatric feeding disorders (PFDs) residing in a metropolitan area completed three questionnaires relating to (a) demographics, (b) time and cost for in-person care and (c) time and cost for telepractice. Both cost questionnaires collected data required for direct and indirect costs comparisons (e.g. out-of-pocket costs associated with the appointment (direct), time away from usual duties (indirect)). Average number of services accessed by each participant, and PFD appointments conducted annually by the service, were collected from service statistics. Analysis involved cost minimisation and cost modelling from a societal perspective.

RESULTS

The telepractice appointment resulted in significant time (p = 0.007) and cost (AUD$95.09 per appointment, SD = AUD$64.47, p = < 0.0001) savings per family. The health service cost was equivalent for both models (AUD$58.25). Cost modelling identified cost savings of up to AUD$475.45 per family if 50% of appointments in a 10-session block were converted to telepractice. Potential cost savings of AUD$68,750.07 per annum to society could be realised if 50% of feeding appointments within the service were provided via telepractice.

DISCUSSION

The telepractice model offered both time and cost benefits. Future service re-design incorporating hybrid services (in-person and telepractice) will help optimise benefits and minimise burden for families accessing services for PFDs.

Telehealth Interventions in Head and Neck Cancer Patients: A Systematic Review

BACKGROUND

Head and neck cancer (HNC) and its treatments often result in adverse effects that impair a patient's quality of life. Although intensive rehabilitative strategies can be used, their applicability can be limited due to patient-specific and socioeconomic barriers. Telehealth interventions represent a possible novel approach to increase access to these services and improve posttreatment quality of life in the HNC population.

OBJECTIVE

The objective of this systematic review was to identify studies investigating telemedicine-based interventions for HNC patients to determine whether there is a consensus concerning the cost-effectiveness, clinical utility, and accessibility of this model for rehabilitation.

METHODS

PubMed, EMBASE, Web of Science, and CINAHL were used to identify literature without time limit for publication. A critical appraisal of individual sources was conducted by 2 reviewers. Sixteen studies met inclusion criteria.

RESULTS

Studies related to telehealth interventions in the HNC population are limited. Salient themes included feasibility of telehealth as an intervention, effects on self-management and knowledge, impact on quality of life, physical and psychiatric symptoms, and cost.

CONCLUSION

Although the current literature presents promising data, indicating that telehealth interventions may be both effective and cost-efficient in the management of HNC patients, more research is needed to definitively elucidate their role in management.

IMPLICATIONS FOR PRACTICE

Telehealth interventions are valuable for clinicians as an alternative to expand access to care across the cancer continuum, to strengthen patients' knowledge and consequently their self-management, and to provide continuity of services as well as for remote monitoring of symptoms and response to treatment.

Remote Assessment: Origins, Benefits, and Concerns

Although guidelines surrounding COVID-19 have relaxed and school-aged students are no longer required to wear masks and social distance in schools, we have become, as a nation and as a society, more comfortable working from home, learning online, and using technology as a platform to communicate ubiquitously across ecological environments. In the school psychology community, we have also become more familiar with assessing students virtually, but at what cost? While there is research suggesting score equivalency between virtual and in-person assessment, score equivalency alone is not sufficient to validate a measure or an adaptation thereof. Furthermore, the majority of psychological measures on the market are normed for in-person administration. In this paper, we will not only review the pitfalls of reliability and validity but will also unpack the ethics of remote assessment as an equitable practice.

Enhancing speech-language pathology head and neck cancer service provision in rural Australia: Using a plan, do, study, act approach

PURPOSE

People with head and neck cancer (HNC) require ongoing speech-language pathology (SLP) services into the post-acute recovery phase of care. However, there are recognised service inequities/barriers for people from rural areas who are unable to access SLP services locally, necessitating travel to metropolitan centres. This study implemented strategies to assist rural speech-language pathologists to work to full scope of practice and support post-acute rehabilitation services for people with HNC.

METHOD

The study involved five SLP departments within a rural health referral network (one tertiary cancer centre, four rural sites). It involved a Plan-Do-Study-Act (PDSA) method, across two six month cycles, to achieve implementation of a model to support local SLP delivery of HNC care. Data collected included service activity, consumer feedback from people accessing local care, staff perceptions of the model and changes to local SLP service capabilities.

RESULT

Staff identified four objectives for change across the two PDSA cycles including resource development, upskilling/training and improving communication, and handover processes. In cycle 1, multiple resources were developed such as an eLearning program for training and skill development. In cycle 2, a pilot trial of a shared-care model was implemented, which successfully supported a transfer of care to local services for eight people with HNC. The majority of consumers accessing HNC care locally were satisfied with the service and would recommend future people with HNC receive similar care.

CONCLUSION

The PDSA process supported development and implementation of a model enabling local speech-language pathologists to offer post-acute care for people with HNC. This model helps rural people with HNC to access care closer to home by supporting rural clinicians to work to full scope of practice.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review

OBJECTIVE

Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL.

REVIEW METHODS

A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost).

RESULTS

Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit).

CONCLUSION

While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Virtual Care Initiatives for Older Adults in Australia: Scoping Review

BACKGROUND

There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia.

OBJECTIVE

We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia.

METHODS

A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework.

RESULTS

Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers.

CONCLUSIONS

Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.

Post-acute health care needs of people with head and neck cancer: Mapping health care services, experiences, and the impact of rurality

BACKGROUND

People with head and neck cancer (HNC) have complex health care needs; however, limited evidence exists regarding the nature or patterns of service access and use. This study explored the post-discharge health care needs and experiences of individuals with HNC from metropolitan and rural areas.

METHODS

Health care appointments and services accessed by people with HNC were collated for 6-month post-treatment. Data analysis of the whole cohort examined patterns of access while journey mapping integrated participants' experiences of recovery.

RESULTS

The 6-month service access journey was mapped for 11 people. Rural participants attended a significantly greater number of appointments (p = 0.012), higher canceled/missed appointments (p = 0.013), and saw more professionals (p = 0.007). Rural participants reported higher stress and burden due to service access barriers and unmet needs.

CONCLUSIONS

Multiple challenges and inequities exist for rural people with HNC. Findings inform opportunities to enhance the post-treatment recovery of people with HNC in rural areas.

Understanding the implementation of telepractice in speech and language services using a mixed-methods approach

Background: Telepractice emerged as a solution to overcome the challenges of access issues in the delivery of healthcare. Telepractice in speech language pathology (SLP) has existed for nearly a decade yet there is a significant knowledge gap with respect to the factors influencing the implementation of telepractice as a routine or long-term, sustained effort. This mixed-methods study aimed to identify implementation factors that influence the provision of telepractice in SLP services.

Method: A mixed-methods study consisting of a scoping review and semi-structured interviews (SSI) was carried out. Articles that described telepractice in SLP were included based on an operational definition of implementation and a set of inclusion criteria.

Results: Data was extracted from 11 studies that were mapped to nine projects in telepractice in SLP. The broad focus areas identified included diagnostics and evaluation, therapeutics and comprehensive assessment, management and follow-up care services. Synchronous/ real-time telepractice methods were always used for the provision of diagnostic testing or when providing therapy services using video conferencing. The ‘ professional-facilitator-patient’ model was used most commonly followed by the ‘ professional-patient’ model.  Barriers for long-term sustainability included inadequate initial capital investment, lack of reimbursement and payment options, low internet speed and bandwidth, resistance and hesitancy to use telepractice from the patient’s end, lack of organizational policies and uniform regulations. Sustainable source of funding, having a dedicated team of professionals and technicians with clear roles and responsibilities, and inclusion of systematic planning facilitated implementation. 

Conclusion: In general, telepractice in SLP was not explicitly guided by implementation science or framework. The use of implementation frameworks ensures systematic planning and feasibility assessment to inform the scale-up of implementation. Therefore, it would be worthwhile for program implementers to consider these aspects when exploring telepractice services.

Patient Satisfaction with Virtual vs In-Person Voice Therapy

OBJECTIVE

To determine whether there is a difference in patient satisfaction between in-person and virtual voice therapy.

METHODS

Patient satisfaction answers to the National Research Corporation (NRC) Health patient survey were retrieved for two separate 11 month periods. The first was for an in-person cohort, from April 2019 to February 2020. The second was for a virtual cohort between April 2020 and February 2021. Two group t tests or Wilcoxon rank sum tests were used to compare responses between the in-person and virtual cohorts. The effect of modality of therapy by gender, age, and race was examined by testing interactions with separate ANOVA models.

RESULTS

Responses were compared between 224 patient satisfaction surveys for the virtual cohort and 309 patient satisfaction surveys for the in-person cohort. Overall, responses were highly favorable in all categories. There were no differences between the in-person and virtual cohorts' responses with respect to three main categories: likelihood of future referral of clinic or provider; communication with provider; and comprehension of the treatment plan. The interaction between modality of therapy delivery and age was significant for the question, "Did you know what to do after your visit," with 18-44 year olds in the in-person group reporting a better understanding of the treatment plan compared to the 18-44 year olds in the virtual therapy cohort (P = 0.004). There were no interactions between modality of therapy and gender, or race.

CONCLUSION

Virtual delivery of voice therapy was associated with comparable visit satisfaction scores to in-person delivery, with both delivery modalities demonstrating very high satisfaction. Future studies are needed to identify which patients and conditions are most suited for virtual versus in-person delivery of speech-language pathology services in voice clinics.

Tele-Assessments in Rural and Remote Schools – Perspectives of Support Teachers

Tele-assessments may enable specialist evaluation of students in schools and their progress following intervention. The aim of this project was to evaluate the feasibility of using videoconferencing technology to assess students with reading difficulties in the school setting and obtain the perspectives of teachers supporting the students during the assessment. Teachers ( n = 57) of 71 primary school age students participated in the study. Teachers provided feedback on the tele-assessment by completing questionnaires about students’ behaviours and the quality of the technology and assessment process. Randomly selected teachers ( n = 24) were invited to participate in a semi-structured interview to provide qualitative feedback. Tele-assessments were completed in 93.4% of the sample. Support teachers reported satisfaction with the audio and visual quality as well as the assessment process. The majority of students completed the tele-assessment with good compliance, engagement and attention. Feedback from support teachers also reflected the strengths of tele-assessments, such as better access to service, cost saving and convenience. Barriers to tele-assessments included technical difficulties, assessment limitations and equipment issues at schools. Tele-assessment is a feasible method of objectively measuring outcomes of students following an intervention. Tele-assessment at school is largely accepted by teachers who supported students in this study. Feedback obtained from this research may be used to offer guidance on undertaking tele-assessments with students in the school setting.

OUP accepted manuscript

Background

Aim

Methods

Results

Conclusions

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

Sustaining allied health telehealth services beyond the rapid response to COVID-19: Learning from patient and staff experiences at a large quaternary hospital

The patient, clinician and administration staff perspectives of telehealth (specifically videoconferencing) services provided by Allied Health Professions (AHP) at a large quaternary hospital were explored. The purpose was to understand stakeholders' perceptions of the service during initial COVID-19 restrictions and examine factors that influenced the implementation and sustained use of telehealth. A sequential mixed-methods approach was undertaken. Stage 1 involved surveys completed by patients (n = 109) and clinicians (n = 66) who received and provided care via telehealth, respectively, across six AHP departments. Stage 2 involved focus groups with clinicians (n = 24) and administrative staff (n = 13) to further examine implementation and sustainability factors.All participant groups confirmed that telehealth was a valid service model and valued the benefits it afforded, particularly during COVID-19 restrictions. Both patients and clinicians reported that not all AHP services could be delivered via telehealth and preferred a blended model of telehealth and in-person care. Increased administrative staff assistance was needed to support growing telehealth demand. Main factors to address are the need to expand AHP telehealth models and workforce/patient training, improve workflow processes and enhance technical support.Despite rapid implementation, telehealth experiences were overall positive. Study findings are being used to generate solutions to enhance and sustain AHP telehealth services.

Rehabilitation Needs of Head and Neck Cancer Patients and Stakeholders: Case Study

Background

The incidents of Head and Neck Cancer (HNC) are rising worldwide, suggesting that this type of cancer is becoming more common. The foreseen growth of incidents signifies that future rehabilitation services will have to meet the needs of a wider population.

Objective

The aim of this paper is to explore the needs of patients, caregivers and healthcare professionals during HNC rehabilitation.

Methods

This paper reports the empirical findings from a case study that was conducted in a cancer rehabilitation center in Copenhagen to elicit the needs of HNC cancer patients, informal caregivers and healthcare professionals.

Results

Four areas of needs during the rehabilitation process were identified: service delivery, emotional, social and physical needs. Service delivery needs and emotional needs have been identified as the most prevalent.

Conclusions

Stakeholders' needs during the rehabilitation process were found to be interrelated. All stakeholders faced service delivery challenges in the form of provision and distribution of information, including responsibilities allocation between municipalities, hospitals and rehabilitation services. Emotional and social needs have been reported by HNC patients and informal caregivers, underlining the importance of inclusion of all actors in the design of future healthcare interventions. Connected Health (CH) solutions could be valuable in provision and distribution of information.

A Preliminary Investigation of Social Justice Perceptions Among U.S. Speech-Language Pathologists: Clinical Implications

Purpose The purpose of this survey research is to provide preliminary data regarding speech-language pathologists' (SLPs') perceptions of the role that social justice (SJ) plays in their work. As our professional organizations call us to advocate and communicate with regulatory agencies and legislative bodies to promote quality care for all individuals, this topic has become particularly important at this time. At present, there is a lack of data in peer-reviewed publications within the discipline of communication disorders on SJ and even less regarding the perceptions of SLPs on SJ. Method The survey was sent to American Speech-Language-Hearing Association (ASHA)-certified SLPs, identified by the ASHA ProFind database, across six U.S. geographic regions, including both urban and rural communities. Four themes were explored through the survey: (a) importance of SJ, (b) awareness of SJ, (c) current practices related to SJ, and (d) barriers to SJ implementation. Results The majority of respondents view SJ as important to the profession (91.2%) and value the work of creating equality among groups (96.0%). Many SLPs are actively involved in implementing SJ principles in their own practice by accepting Medicaid (40.7%), engaging in political outreach (55.0%), and providing transdisciplinary educational outreach (77.9%). Identified barriers to incorporating SJ include time (62.7%), resources (65.6%), and finances (70.0%). Conclusions Working for SJ is important to a majority of the respondents, and various efforts are implemented to create equal opportunities for service to clients. Barriers continue to exist that limit the degree to which SLPs can work toward SJ. A list of actions to be considered in order to promote SJ in the field is provided. Supplemental Material https://doi.org/10.23641/asha.16584044.

Speech pathology service enhancement for people with head and neck cancer living in rural areas: Using a concept mapping approach to inform service change

BACKGROUND

Speech pathology (SP) services provide swallowing and communication intervention to people with head and neck cancer (HNC) across the continuum of care. However, difficulties exist with access and delivery of services in rural areas. The study aim was to identify actionable goals for SP change, utilizing a concept mapping approach.

METHODS

Eleven SP staff from two regional/remote services completed the concept mapping process. Multivariate analysis and multidimensional scaling were used to develop a final set of prioritized goals for change.

RESULTS

Between the two participating health services, 30 actionable goals were identified within the "green-zone" on the go-zone graph of importance and changeability. Among the most highly rated areas for change was the need to deliver and receive more support for training, mentoring, and supervision to consolidate skills.

CONCLUSIONS

This methodology enabled identification of prioritized, actionable changes to improve SP services for people with HNC living in regional/remote areas.

Evaluating the Use of Telepractice to Deliver Pediatric Feeding Assessments

Purpose This study aimed to investigate the interrater reliability of pediatric feeding assessments conducted via synchronous (real-time) telepractice. Secondary aims were to investigate parent and clinician satisfaction. Method The eating and/or cup drinking skills of 40 children (aged 4 months to 7 years) were simultaneously assessed by one speech-language pathologist (SLP) leading the appointment via telepractice and a second SLP present in the family home. A purpose-designed assessment form was used to assess (a) positioning, (b) development, (c) oral sensorimotor function, (d) prefeeding respiratory status, (e) observation of eating and drinking, (f) parent-child interaction, (g) overall feeding skills, and (h) feeding recommendations. The telepractice SLP completed a postappointment satisfaction questionnaire, and parents completed five questionnaires specifically investigating perceptions of and satisfaction with the telepractice feeding appointment. Results Agreement for all assessment components except intraoral examination (palate integrity and tonsils) was > 85%. All appointments were able to be conducted via telepractice, and for 90% of these (n = 36), clinicians agreed that telepractice was an effective service delivery method. Parents reported high levels of satisfaction with telepractice, with 76% reporting that the telepractice appointment was similar to a traditional in-person appointment. Conclusion Study results demonstrated that synchronous pediatric feeding assessments conducted in family homes via telepractice were feasible, reliable, and acceptable to both clinicians and parents. Supplemental Material https://doi.org/10.23641/asha.14700228.

Improving Access to Care: Telemedicine Across Medical Domains

Over the past 20 years, the use of telemedicine has increased exponentially. Its fundamental aim is to improve access to care. In this review, we assess the extent to which telemedicine has fulfilled this promise across medical domains. Additionally, we assess whether telemedicine has improved related health outcomes. Finally, we determine who has benefited from this novel form of health care delivery. A review of the literature indicates that (a) telemedicine has improved access to care for a wide range of clinical conditions ranging from stroke to pregnancy; (b) telemedicine in select circumstances has demonstrated improved health outcomes; and (c) telemedicine has addressed geographical, but less so social, barriers to care. For telemedicine to fulfill its promise, additional evidence needs to be gathered on health outcomes and cost savings, the digital divide needs to be bridged, and policy changes that support telemedicine reimbursement need to be enacted.

The Out-of-Pocket Cost Burden of Cancer Care-A Systematic Literature Review

BACKGROUND

Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care.

METHODS

A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs.

RESULTS

Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15-400 in Canada, USD 4-609 in Western Europe, and USD 58-438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40-71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively.

CONCLUSIONS

We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review

BACKGROUND

Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.

OBJECTIVE

This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.

METHODS

A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.

RESULTS

The cost analyses reviewed provided evidence that telehealth reduced costs when health system-funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.

CONCLUSIONS

Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The breakeven point for implementing telehealth

INTRODUCTION

There are finite resources available to spend on healthcare, with the increasing burden of disease and the increasing cost of providing healthcare it is imperative that methods for optimising health systems to improve sustainability are investigated. This study is part of a larger body of work investigating the potential for telehealth to improve the economic sustainability of the health system. The aim of this sub-analysis is to investigate the breakeven point for implementing a telehealth service; that is the point after which the initial investment is recouped and the cost savings have become tangible.

METHOD

Literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature focusing on telehealth. Articles were included if they reported their findings from a health system perspective, demonstrated cost savings, and provided sufficient information to calculate the breakeven point.

RESULTS

Less than half of the economic analysis studies examined reported cost savings for the health system as a result of telehealth. The breakeven point could be calculated for 12 articles, all of which were included in the analysis. These articles described evaluations for store-and-forward, remote monitoring and videoconference services. The breakeven points for these services ranged from near immediate (less than 1 year) to 9 years. Remote monitoring and store-and-forward services reached their breakeven points sooner than the videoconference services.

CONCLUSION

The results demonstrated that telehealth is cost saving for the health system in a proportion of services. When costs are saved, the breakeven point can be immediate (less than 1 year) or may take more time to eventuate.

"It Takes a Whole Day, Even Though It's a One-Hour Appointment!" Factors Impacting Access to Pediatric Feeding Services

Feeding disorders can have a significant impact on children and their families. Access to supportive multidisciplinary care is central to improving outcomes; however, there are numerous factors that can impact service access. Using a mixed methods design, the current study examined parents' experiences and satisfaction with accessing a state-wide government-funded tertiary pediatric feeding clinic in Australia. Parents of 37 children (aged 7 weeks to 17 years) participated in the study, residing 6-1435 km from the service. Each completed questionnaires regarding satisfaction (Client Satisfaction Questionnaire-8 Child Services) and costs, and participated in a semi-structured interview. Costs were measured as both direct (e.g., accommodation) and indirect (measured as lost productivity) associated with accessing their feeding appointment. Results revealed parents were highly satisfied with their child's feeding services, but considerable impacts were reported in accessing the service with 85% of the group noting that attending their child's appointment took at least half a day. The total cost per appointment ranged between $53 and $508 Australian dollars. Interviews identified three main barrier themes: distance and travel, impact on daily activities (e.g., work, school), and parent perception of inaccurate representation of their child's feeding skills within the clinic environment. The issues raised were also tempered by an overarching theme of parental willingness to do "whatever was needed" to meet their child's needs, regardless of these barriers. Service providers should be cognizant of the factors that impact access for families and consider alternative service-delivery models where appropriate to help reduce family burden associated with accessing necessary care.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Implementation of speech pathology telepractice services for clinical swallowing assessment: An evaluation of service outcomes, costs and consumer satisfaction

Introduction

Timely assessment of swallowing disorders (dysphagia) by speech pathologists helps minimise patient risk, optimise quality of life, and limit healthcare costs. This study involved a multi-site implementation of a validated model for conducting adult clinical swallowing assessments via telepractice and examined its service outcomes, costs and consumer satisfaction.

Methods

Five hub-spoke telepractice services, encompassing 18 facilities were established across a public health service. Service implementation support, including training of the telepractice speech pathologists (T-SP) and healthcare support workers in each site, was facilitated by an experienced project officer. New referrals from spoke sites were managed by the hub T-SP as per published protocols for dysphagia assessments via telepractice. Data was collected on existing service models prior to implementation, and then patient demographics, referral information, session outcomes, costs and patient and T-SP satisfaction when using telepractice.

Results

The first 50 sessions were analysed. Referrals were predominantly for inpatients at spoke sites. Telepractice assessments were completed successfully, with only minor technical issues. Changes to patient management (i.e. food/fluid changes post assessment) to optimise safety or progress oral intake, was required for 64% of patients. Service and cost efficiencies were achieved with an average 2-day reduction in waiting time and an average cost benefit of $218 per session when using the telepractice service over standard care. High clinician and patient satisfaction was reported.

Conclusion

Telepractice services were successfully introduced across multiple sites, and achieved service and cost benefits with high consumer satisfaction.

Nutrition and swallowing therapy strategies for patients with head and neck cancer

Patients with head and neck cancer experience many problems with eating which make them at high risk of malnutrition. Pre-habilitation swallowing exercises as overseen by a speech pathologist can improve swallowing function. A multidisciplinary approach to care, including effective nutritional screening, assessment and intervention has demonstrated improved outcomes in terms of meet nutritional requirements, improved nutritional status and quality of life. Nutritional recommendations are 1.2-1.5 g protein per kilogram per day and 125kJ/kg body weight per day but as these are guides close monitoring of intake and weight is important. Multidisciplinary teams and telehealth have shown better outcomes for nutrition and swallowing status for head and neck cancer patients and ongoing support is required for best patient care.

Building a Successful Voice Telepractice Program

PURPOSE

Telepractice offers prevention, assessment, treatment, and consultation at a distance. This article provides an overview of telepractice with specific considerations and examples related to voice across licensure requirements, state and federal laws, reimbursement, documentation, and telepractice methods.

CONCLUSION

As technology continues to advance and as client demand for telepractice services increases, practitioners need to create successful telepractice programs.