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Bharadwaj M, Langbein B, Labban M, Lipsitz SR, Licurse AM, Trinh QD. Patterns and Disparities in Telehealth Usage During the COVID-19 Pandemic Across Surgical Specialties. Telemed J E Health 2024; 30:866-873. [PMID: 37699226 DOI: 10.1089/tmj.2022.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background: The COVID-19 pandemic has accelerated telehealth usage. This study aims to understand the impact of sociodemographic factors on telehealth usage during COVID-19 among surgical specialties. Methods: Our data contain surgical outpatient visits at an academic center from five periods between 2019 and 2020. A difference-in-differences regression model was used to examine the effect of exposure variables on virtual visit proportions between prepandemic and postpandemic time periods. Results: Compared with white patients, non-Medicare beneficiaries, and English-proficient patients, the rate of uptake in telehealth visits from prepandemic to postpandemic periods was lower for black patients, Medicare beneficiaries, and non-English-speaking patients, respectively. Surgical subspecialties saw varied usage of telehealth. A strong preference for phone visits by black patients, Medicare beneficiaries, and non-English-speaking patients existed. Conclusion: Phone visits are an important resource for marginalized communities. Understanding disparities in telemedicine usage may inform policy that could alleviate inequities in health care access.
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Affiliation(s)
- Maheetha Bharadwaj
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bjoern Langbein
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adam M Licurse
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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2
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Sargsyan N, Karunaratne D, Masani A, Howell L, Yousif M. ENT Telephone Clinics During the Coronavirus Pandemic: An Analysis of 400 Telephone Consultations at a District General Hospital. EAR, NOSE & THROAT JOURNAL 2023; 102:733-738. [PMID: 34167356 DOI: 10.1177/01455613211028091] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic led to the introduction of telephone consultations in order to provide specialist health care remotely. This study analyses the outcomes of ear, nose, and throat (ENT) telephone consultations. METHODS Retrospective analysis was undertaken of 400 ENT telephone consultations. RESULTS All 2-week-wait neck or face lump patients underwent imaging and 78% were successfully discharged. 80% of vertigo patients and 100% of 2-week-wait throat symptom patients were offered face-to-face consultations. All primary hyperparathyroidism patients were managed remotely, being discharged, or with telephone follow-up. The majority of routine referrals were managed without the need for face-to-face consultation. CONCLUSION Vertigo patients and 2-week-wait throat symptom patients should be offered a face-to-face consultation in the first instance. For patients with neck or face lumps, initial referral for imaging may improve patient flow and facilitate safe discharge. It is appropriate to continue with telephone consultations for all other patient groups.
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Affiliation(s)
- Narek Sargsyan
- Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, East Sussex, United Kingdom
| | - Dilhara Karunaratne
- Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, East Sussex, United Kingdom
| | - Alisha Masani
- Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, East Sussex, United Kingdom
| | - Lauren Howell
- Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, East Sussex, United Kingdom
| | - Madi Yousif
- Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, East Sussex, United Kingdom
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McKenna VS, Roberts RM, Friedman AD, Shanley SN, Llico AF. Impact of naturalistic smartphone positioning on acoustic measures of voicea). THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2023; 154:323-333. [PMID: 37450331 DOI: 10.1121/10.0020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
Smartphone technology has been used for at-home health monitoring, but there are few available applications (apps) for tracking acoustic measures of voice for those with chronic voice problems. Current apps limit the user by restricting the range of smartphone positions to those that are unnatural and non-interactive. Therefore, we aimed to understand how more natural smartphone positions impacted the accuracy of acoustic measures in comparison to clinically acquired and derived measures. Fifty-six adults (11 vocally healthy, 45 voice disordered, aged 18-80 years) completed voice recordings while holding their smartphones in four different positions (e.g., as if reading from the phone, up to the ear, etc.) while a head-mounted high-quality microphone attached to a handheld acoustic recorder simultaneously captured voice recordings. Comparisons revealed that mean fundamental frequency (Hz), maximum phonation time (s), and cepstral peak prominence (CPP; dB) were not impacted by phone position; however, CPP was significantly lower on smartphone recordings than handheld recordings. Spectral measures (low-to-high spectral ratio, harmonics-to-noise ratio) were impacted by the phone position and the recording device. These results indicate that more natural phone positions can be used to capture specific voice measures, but not all are directly comparable to clinically derived values.
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Affiliation(s)
- Victoria S McKenna
- Department of Communication Sciences and Disorders, University of Cincinnati, Cincinnati, Ohio 45267, USA
| | - Rachel M Roberts
- Department of Communication Sciences and Disorders, University of Cincinnati, Cincinnati, Ohio 45267, USA
| | - Aaron D Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio 45267, USA
| | - Savannah N Shanley
- Department of Communication Sciences and Disorders, University of Cincinnati, Cincinnati, Ohio 45267, USA
| | - Andres F Llico
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio 45221, USA
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4
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Hakanen O, Tolvi M, Torkki P. Cost analysis of face-to-face visits, virtual visits, and a digital care pathway in the treatment of tonsillitis patients. Am J Otolaryngol 2023; 44:103868. [PMID: 36996515 DOI: 10.1016/j.amjoto.2023.103868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE The aim of this study was to compare the costs of two different telemedicine-assisted tonsillitis care pathways with traditional face-to-face visits at the Department of Otorhinolaryngology - Head and Neck Surgery (ORL-HNS) at Helsinki University Hospital. METHODS We characterized and analyzed the patient flows and their individual episodes of all tonsillitis patients at the Department of ORL-HNS between September 2020 and August 2022. Records were collected by doctors at the clinic. We investigated costs and allocated resources in four categories: invoice from the Department of ORL-HNS to the public payer, expenses to the Department, patient fees, and doctor's resource. RESULTS At least a third of the tonsillitis patients were eligible for telemedicine. The digital care pathway was 12.6 % less expensive for the public payer compared to the previous virtual visit model. For the Department, the expense of the digital care pathway was 58.8 % less per patient than the virtual visit model. Patient fees decreased 79.5 %. The digital care pathway reduced the doctor's resource from 30.28 min to 19.78 min, which accounts for a 34.7 % reduction. Patients finished the digital care pathway in a median of 62 min (SD = 60) compared to the 2-4 h which they would spend on an outpatient clinic visit. CONCLUSION Our study demonstrates that tonsillitis patients are eligible for preoperative telemedicine. With at least a third of the tonsillitis patients being eligible for telemedicine, major cost savings can be achieved with efficient e-health-assisted solutions.
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5
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Acosta LA, Aamer S, Becher M, Cucalon Calderon J. Juvenile Ossifying Fibroma and Socioeconomic Barriers to Specialty Care: A Pediatric Case Study. Cureus 2023; 15:e40059. [PMID: 37425522 PMCID: PMC10325821 DOI: 10.7759/cureus.40059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 07/11/2023] Open
Abstract
Juvenile ossifying fibroma (JOF) is a rare benign neoplastic fibro-osseous tumor commonly found in the maxilla and mandible of children usually between the ages of five and 15. Patients often present with aggressive, painless growth which is well demarcated from surrounding bone resulting in severe facial asymmetry. JOFs have high recurrence rates if not completely resected and should therefore be treated by a multidisciplinary team of physicians including a neurosurgeon to assess cranial nerve function. This case describes a child who presented to the ED after being referred by his primary care provider for facial swelling. The patient was diagnosed with JOF and had a delay in care due to a lack of access to multidisciplinary specialties to provide care due to payer difficulties which placed the patient at high risk of complications.
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Affiliation(s)
- Lizeth A Acosta
- Pediatrics and Child Health, University of Nevada Reno School of Medicine, Reno, USA
| | - Sarah Aamer
- Pediatrics and Child Health, University of Nevada Reno School of Medicine, Reno, USA
| | - Monica Becher
- Pediatrics and Child Health, University of Nevada Reno School of Medicine, Reno, USA
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Koopirom P, Wiriyaamornchai P, Santeerapharp A. Telemedicine in Thai-otorhinolaryngology patients in COVID-19 situation; primary surveys. Digit Health 2022; 8:20552076221147795. [PMID: 36601287 PMCID: PMC9806494 DOI: 10.1177/20552076221147795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/08/2022] [Indexed: 12/28/2022] Open
Abstract
Introduction COVID-19 pandemic has put a strain on various aspects of hospital management due to high rates of infection and increased preventive measures around the world. Physicians and patients alike are susceptible to the ongoing virus causing concern leading to loss or postpone of follow up. Thailand has just start integration of digital solutions such as telemedicine which expected similar level of medical care and efficiency while reducing risk of exposure during the COVID-19 pandemic. Objective Evaluation the willingness to accept telemedicine in otorhinolaryngology patients during the peak COVID-19 outbreaks in our institution. Methods Collected data from all patients who had a schedule follow up for otorhinolaryngology department between the months of June to August, 2021 at out-patient Center. Results Total of 299 otorhinolaryngology patients included, 213 patients (71.2%) denied a virtual medical visit whereas 86 patients (28.8%) accepted. The obstructive sleep apnea (OSA) was the only group to have more acceptance of telemedicine, 79.5% than denying 20.5% with statistical significance (p < 0.01). Age difference between the accepting and declining group also showed statistical significance, 48.5 years and 56 years respectively (p < 0.01). Main Reasons for their decision, 48% of patients accepted due to experiencing clinical improvement and stability. The main reason for not accepting telemedicine was 80% of patients preferred a special otorhinolaryngologic examination on follow up. Conclusions This primary surveys among Thai otorhinolaryngology patients about telemedicine. The greater number of patients not interested in telemedicine due to requirement of otorhinolaryngologic examination. Which OSA follow-up patients have more attention in telemedicine.
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Affiliation(s)
| | | | - Alena Santeerapharp
- Alena Santeerapharp, Department of
Otolaryngology-Head & Neck Surgery, Faculty of Medicine, Srinakharinwirot
University, Bangkok, Thailand.
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7
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Tzeng YH, Yin WH, Lin KC, Wei J, Liou HR, Sung HJ, Lang HC. Factors Associated With the Utilization of Outpatient Virtual Clinics: Retrospective Observational Study Using Multilevel Analysis. J Med Internet Res 2022; 24:e40288. [PMID: 35917486 PMCID: PMC9377537 DOI: 10.2196/40288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/25/2022] [Accepted: 07/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background Although the COVID-19 pandemic has accelerated the adoption of telemedicine and virtual consultations worldwide, complex factors that may affect the use of virtual clinics are still unclear. Objective This study aims to identify factors associated with the utilization of virtual clinics in the experience of virtual clinic service implementation in Taiwan. Methods We retrospectively analyzed a total of 187,742 outpatient visits (176,815, 94.2%, in-person visits and 10,927, 5.8%, virtual visits) completed at a large general hospital in Taipei City from May 19 to July 31, 2021, after rapid implementation of virtual outpatient clinic visits due to the COVID-19 pandemic. Data of patients’ demographic characteristics, disease type, physicians’ features, and specialties/departments were collected, and physicians’ opinions regarding virtual clinics were surveyed and evaluated using a 5-point Likert scale. Multilevel analysis was conducted to determine the factors associated with the utilization of virtual clinics. Results Patient-/visit-, physician-, and department-level factors accounted for 67.5%, 11.1%, and 21.4% of the total variance in the utilization of virtual clinics, respectively. Female sex (odds ratio [OR] 1.27, 95% CI 1.22-1.33, P<.001); residing at a greater distance away from the hospital (OR 2.36, 95% CI 2.15-2.58 if distance>50 km, P<.001; OR 3.95, 95% CI 3.11-5.02 if extensive travel required, P<.001); reimbursement by the National Health Insurance (NHI; OR 7.29, 95% CI 5.71-9.30, P<.001); seeking care for a major chronic disease (OR 1.33, 95% CI 1.24-1.42, P<.001); the physician’s positive attitude toward virtual clinics (OR 1.50, 95% CI 1.16-1.93, P=.002); and visits within certain departments, including the heart center, psychiatry, and internal medicine (OR 2.55, 95% CI 1.46-4.46, P=.004), were positively associated with the utilization of virtual clinics. The patient’s age, the physician’s age, and the physician’s sex were not associated with the utilization of virtual clinics in our study. Conclusions Our results show that in addition to previously demonstrated patient-level factors that may influence telemedicine use, including the patient’s sex and distance from the hospital, factors at the visit level (insurance type, disease type), physician level (physician’s attitude toward virtual clinics), and department level also contribute to the utilization of virtual clinics. Although there was a more than 300-fold increase in the number of virtual visits during the pandemic compared with the prepandemic period, the majority (176,815/187,742, 94.2%) of the outpatient visits were still in-person visits during the study period. Therefore, it is of great importance to understand the factors impacting the utilization of virtual clinics to accelerate the implementation of telemedicine. The findings of our study may help direct policymaking for expanding the use of virtual clinics, especially in countries struggling with the development and promotion of telemedicine virtual clinic services.
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Affiliation(s)
- Yun-Hsuan Tzeng
- Health Management Center, Cheng Hsin General Hospital, Taipei, TW.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, TW
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, TW.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, TW
| | - Kuan-Chia Lin
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei, TW.,Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, TW
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, TW
| | - Hao-Ren Liou
- Health Management Center, Cheng Hsin General Hospital, Taipei, TW
| | - Hung-Ju Sung
- Health Management Center, Cheng Hsin General Hospital, Taipei, TW
| | - Hui-Chu Lang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei, TW
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8
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Yang A, Kim D, Hwang PH, Lechner M. Telemedicine and Telementoring in Rhinology, Otology, and Laryngology: A Scoping Review. OTO Open 2022; 6:2473974X211072791. [PMID: 35274073 PMCID: PMC8902203 DOI: 10.1177/2473974x211072791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Telemedicine and telementoring have had a significant boost across
all medical and surgical specialties over the last decade and
especially during the COVID-19 pandemic. The aim of this scoping
review is to synthesize the current use of telemedicine and
telementoring in otorhinolaryngology and head and neck
surgery. Data Sources PubMed and Cochrane Library. Review Methods A scoping review search was conducted, which identified 469
articles. Following full-text screening by 2 researchers, 173
articles were eligible for inclusion and further categorized via
relevant subdomains. Conclusions Virtual encounters and telementoring are the 2 main applications of
telemedicine in otolaryngology. These applications can be
classified into 7 subdomains. Different ear, nose, and throat
subspecialties utilized certain telemedicine applications more
than others; for example, almost all articles on patient
engagement tools are rhinology based. Overall, telemedicine is
feasible, showing similar concordance when compared with
traditional methods; it is also cost-effective, with high
patient and provider satisfaction. Implications for Practice Telemedicine in otorhinolaryngology has been widely employed during
the COVID-19 pandemic and has a huge potential, especially with
regard to its distributing quality care to rural areas. However,
it is important to note that with current exponential use, it is
equally crucial to ensure security and privacy and integrate
HIPAA-compliant systems (Health Insurance Portability and
Accountability Act) in the big data era. It is expected that
many more applications developed during the pandemic are here to
stay and will be refined in years to come.
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Affiliation(s)
- Angela Yang
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Dayoung Kim
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Peter H. Hwang
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Matt Lechner
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
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Urban MJ, Shimomura A, Shah S, Losenegger T, Westrick J, Jagasia AA. Rural Otolaryngology Care Disparities: A Scoping Review. Otolaryngol Head Neck Surg 2022; 166:1219-1227. [PMID: 35015580 DOI: 10.1177/01945998211068822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. STUDY DESIGN Scoping review. DATA SOURCES A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. REVIEW METHODS The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. RESULTS The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. CONCLUSION Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.
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Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Aoi Shimomura
- Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Swapnil Shah
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Tasher Losenegger
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Ashok A Jagasia
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Haleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. SENSORS INTERNATIONAL 2021; 2:100117. [PMID: 34806053 PMCID: PMC8590973 DOI: 10.1016/j.sintl.2021.100117] [Citation(s) in RCA: 167] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022] Open
Abstract
Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.
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Affiliation(s)
- Abid Haleem
- Department of Mechanical Engineering, Jamia Millia Islamia, New Delhi, India
| | - Mohd Javaid
- Department of Mechanical Engineering, Jamia Millia Islamia, New Delhi, India
| | - Ravi Pratap Singh
- Department of Industrial and Production Engineering, Dr B R Ambedkar National Institute of Technology, Jalandhar, Punjab, India
| | - Rajiv Suman
- Department of Industrial & Production Engineering, G.B. Pant University of Agriculture & Technology, Pantnagar, Uttarakhand, India
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Choi JS, Kim JH, Park S, Lin M, Abdur-Rahman F, Mack WJ, Volker CCJ. Telemedicine in Otolaryngology During COVID-19: Patient and Physician Satisfaction. Otolaryngol Head Neck Surg 2021; 167:56-64. [PMID: 34491856 DOI: 10.1177/01945998211041921] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine patient and physician satisfaction with telemedicine in otolaryngology during COVID-19 and identify associated factors. STUDY DESIGN Prospective cohort study. SETTING Tertiary care center. METHODS Patient satisfaction was rated by patients (age ≥18 years) who had encounters from May to July 2020 (n = 407). Physician satisfaction was rated by 15 otolaryngologists for specific encounters delivered from May to June 2020 (n = 1011). Patient satisfaction was measured with a Press Ganey questionnaire and a Telemedicine Satisfaction Questionnaire. Mean Press Ganey satisfaction scores of telemedicine encounters during COVID-19 were compared with the pre-COVID-19 Press Ganey scores from in-person encounters (n = 3059) to test a noninferiority hypothesis. Physician satisfaction was measured with a Provider Satisfaction Questionnaire. RESULTS The mean Press Ganey patient satisfaction score for telemedicine encounters was 94.5 (SD, 8.8), no worse than that for in-person encounters prior to COVID-19 at 93.7 (SD, 15.5; Δ = 0.8 [95% CI, -0.5 to 2.1, excluding the noninferiority margin of -1]). Encounters with videoconference (vs telephone) and patients reporting higher income were associated with higher Telemedicine Satisfaction Questionnaire scores. Physician satisfaction scores during COVID-19 with telemedicine encounters were overall high at 83.3 (95% CI, 77.5-89.1), slightly lower when compared with the scores with in-person encounters at 88.4 (95% CI, 82.5-94.3; Δ = -5.2 [95% CI, -6.6 to -3.8]). Encounters with videoconference (vs telephone) and patients with English as a preferred language and follow-up visits were associated with higher Provider Satisfaction Questionnaire scores. CONCLUSIONS Telemedicine is a feasible alternative format in otolaryngology during COVID-19 with overall high patient and physician satisfaction. Patient satisfaction with telemedicine encounters during COVID-19 was no worse than in-person encounters prior to the pandemic. Physician satisfaction with telemedicine was relatively lower in comparison with in-person encounters.
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Affiliation(s)
- Janet S Choi
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - James H Kim
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Soyun Park
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Matthew Lin
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Faiz Abdur-Rahman
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Courtney C J Volker
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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12
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Sclafani AP, Shomorony A, Stewart MG, Grunstein E, Overdevest JB. Telemedicine lessons learned during the COVID-19 pandemic: The augmented outpatient otolaryngology teleconsultation. Am J Otolaryngol 2021; 42:102960. [PMID: 33610921 PMCID: PMC7883738 DOI: 10.1016/j.amjoto.2021.102960] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 12/20/2022]
Abstract
Purpose Telemedicine use in otolaryngology waxed and waned during the COVID-19 pandemic outbreak in the U.S. Assessing the patterns of telemedicine use and its perceived limitations during the COVID-19 outbreak in 2020 allows identification and correction of impediments to consistent telemedicine use by otolaryngologists. Materials and methods Full-time faculty of 2 academic otolaryngology departments in New York City were surveyed regarding their telemedicine use from March through August 2020 during the “first wave” of the COVID-19 pandemic. Based on these findings, a method of “augmented outpatient otolaryngology teleconsultation” designed to enhance the quality of the physical examination was developed and employed from August to December 2020. Patients receiving this augmented teleconsult were anonymously surveyed about their telemedical experience. Results Telemedicine use by faculty was minimal prior to the pandemic, but as total outpatient volume decreased 65–84% across subspecialties, it was used by all otolaryngologists during COVID-19. Physicians were less confident in making a telemedical diagnosis at all phases of the study in all subspecialties. Patients who had an augmented otolaryngology teleconsultation were satisfied with it, believed it facilitated earlier care, limited the time and cost of travel to the physician's office and felt their physician was able to perform a sufficient physical examination. Conclusions During the COVID-19 crisis, physicians utilized teleotolaryngology to provide care but were less satisfied with their ability to make an accurate diagnosis. Inexpensive direct-to-consumer digital otoscopes can improve the quality of the physical examination provided and can address both patient and physician needs.
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Comparing telehealth with office-based visits for common pediatric otolaryngology complaints. Int J Pediatr Otorhinolaryngol 2021; 145:110712. [PMID: 33887549 DOI: 10.1016/j.ijporl.2021.110712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility of telehealth visits and compare office-based visits for pediatric patients undergoing evaluation of recurrent acute otitis media or sleep-disordered breathing. METHODS A retrospective cohort study compared telehealth patients with matched controls seen in the office. The feasibility of a thorough patient evaluation in a single telehealth visit without a follow-up office visit was assessed. Both groups were also compared for completeness of physical exam, management, follow-up recommendations, and correlation of physical exam findings with intraoperative findings. RESULTS 100 children [mean age (SD) = 20.7 (15.6) months] with a chief complaint of recurrent acute otitis media and 128 children [5.4 (3.2) years] with a chief complaint of sleep-disordered breathing were evaluated. Recommendations for surgery, additional studies, or routine follow-up were similar between telehealth and office-based groups. Physical exam feasibility was significantly different for the nasal cavity, oropharynx, and middle ear (P < .001). Patients who underwent office-based consultation were much more likely to have findings of middle ear fluid at the time of tympanostomy tube placement (79.3% vs 39.3%, P = .002). There was no significant difference between preoperative and intraoperative tonsil size discrepancies (P = .749). CONCLUSION Telehealth can be used successfully for the evaluation of pediatric patients with sleep-disordered breathing; however, reliance on history alone may result in unnecessary tympanostomy tube placement in patients with recurrent acute otitis media. Physical examination of the oropharynx, nasal cavity, and middle ear via telehealth presents a unique challenge in pediatric otolaryngology.
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Hentati F, Cabrera CI, D'Anza B, Rodriguez K. Patient satisfaction with telemedicine in rhinology during the COVID-19 pandemic. Am J Otolaryngol 2021; 42:102921. [PMID: 33508592 PMCID: PMC7834232 DOI: 10.1016/j.amjoto.2021.102921] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/29/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The COVID-19 pandemic has forced the rapid integration of telemedicine services across several specialties, especially in Otolaryngology where risk of transmission is very high. Studies before and during the COVID-19 pandemic have shown that Otolaryngology is generally amenable to telemedicine. However, few studies have assessed patient satisfaction with telemedicine during the COVID-19 pandemic, and fewer have focused on patient satisfaction with telehealth in Rhinology. OBJECTIVES To determine if patients believe the benefits of virtual live synchronous telemedicine visits out-weigh the drawbacks when compared to in-person clinical visits. METHODS Single center retrospective case series and survey study of patients presenting to a tertiary care Rhinology practice between 3/15/2020 and 6/1/2020. All patients had previous in-person encounters with Rhinology (n = 45). RESULTS Twenty-nine participants (64.4%) had audio-video visits while 16 (35.6%) had audio visits. 36 (80%) patients stated that their needs were met during their telemedicine visit while 32 (71.1%) patients felt that nothing was missed or not addressed during the virtual visit. The most commonly cited advantage to telemedicine visits was convenience (22.2%) and provider availability (20.0%). While most participants did not disclose a disadvantage to a virtual visit besides the lack of a physical exam (68.9%), the most commonly cited disadvantage to a virtual visit was technological difficulties (17.8%). CONCLUSIONS Virtual telemedicine visits were shown to effectively meet the needs of established patients and address concerns in a convenient time efficient manner. However, patients indicated that limited technology and a less personalized feel hindered the telemedicine experience in Rhinology.
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Sethia R, Freeman T, Mead K, Selhorst A, Vala K, Skoracki L, Adelman M, VanKoevering K, Kang SY, Ozer E, Agrawal A, Old MO, Carrau RL, Rocco JW, Seim NB. Patient-Directed Home Drain Removal in Head and Neck Surgery. Laryngoscope 2021; 131:2471-2477. [PMID: 33847392 DOI: 10.1002/lary.29556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/27/2021] [Accepted: 03/31/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Rishabh Sethia
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Taylor Freeman
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Katherine Mead
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Amanda Selhorst
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Kelly Vala
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Laura Skoracki
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Megan Adelman
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Kyle VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
| | - Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Division of Head and Neck Oncology and Microvascular Reconstructive Surgery, The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, U.S.A
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Gupta T, Gkiousias V, Bhutta MF. A systematic review of outcomes of remote consultation in ENT. Clin Otolaryngol 2021; 46:699-719. [PMID: 33754458 DOI: 10.1111/coa.13768] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/11/2021] [Accepted: 03/14/2021] [Indexed: 12/18/2022]
Abstract
AIMS Remote or tele-consultation has become an emerging modality of consultation in many specialities, including ENT. Advantages include increasing accessibility, potential to reduce costs and, during the COVID-19 pandemic, reduced risk of infection transmission. Here, we systematically collate and synthesise the evidence base on outcomes from remote consultation in adult and paediatric ENT services. METHODS We performed a review in accordance with PRISMA guidelines. We searched Medline and Embase for relevant articles. Outcomes include specific patient pathway efficiency measures (including number of healthcare visits, lead time, touch time and handoff), patient/clinician satisfaction, cost analysis and safety implications. RESULTS From 6325 articles screened, 53 met inclusion criteria. Publications included studies on remote consultation for initial, preoperative and follow-up assessment (including postoperative). In most instances, remote consultation reduced costs and time from referral to assessment and was associated with high patient satisfaction. However, a face-to-face follow-up appointment was required in 13%-72% of initial consultations, suggesting that remote consultation is only appropriate in selected cases. CONCLUSION Remote consultation is appropriate and preferable for ENT consultation in specific conditions and circumstances. Future research should look to better define those conditions and circumstances, and report using recognised quality standards and outcome measures.
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Affiliation(s)
- Tanya Gupta
- Ear, Nose and Throat Department, Royal Sussex County Hospital, Brighton, UK
| | | | - Mahmood F Bhutta
- Ear, Nose and Throat Department, Royal Sussex County Hospital, Brighton, UK.,Brighton & Sussex Medical School, Falmer, Brighton, UK
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Metzger G, Jatana K, Apfeld J, Deans KJ, Minneci PC, Halaweish I. State of telemedicine use in pediatric surgery in the USA—where we stand and what we can gain from the COVID-19 pandemic: a scoping review. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000257. [DOI: 10.1136/wjps-2020-000257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundWithin the last decade, the use of telemedicine within in primary care in the USA has greatly expanded; however, use remains uncommon in surgical specialties. The spread of Coronavirus disease 2019 (COVID-19) prompted healthcare institutions to limit in-person contact, resulting in an increase in telemedicine across all specialties, including pediatric surgery. The aims of this review were to evaluate potential barriers that limited the use of telemedicine in pediatric surgery prior to the COVID-19 period and to define how best to incorporate its use into a pediatric surgical practice going forward.MethodsA scoping review was performed to identify gaps in the literature pertaining to the use of telemedicine within general pediatric surgery in the USA prior to the outbreak of COVID-19. Next, a focused evaluation of the legislative and organizational policies on telemedicine was performed. Lastly, findings were summarized and recommendations for future research developed in the context of understanding and overcoming barriers that have plagued widespread adoption in the past.ResultsDespite evidence of telemedicine being safe and well received by adult surgical patients, a total of only three studies representing original research on the use of telemedicine within pediatric surgery were identified. Legislative and organizational policies regarding telemedicine have been altered in response to COVID-19, likely resulting in an increase in the use of telemedicine among pediatric surgeons.ConclusionsTelemedicine offers a safe and effective option for patients seeking an alternative to the in-person clinic appointment. The increased utilization of telemedicine during the COVID-19 pandemic will provide an opportunity to learn how best to leverage the technology to decrease disparities and to overcome previous barriers.
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Takano K, Kaizaki A, Kimura A, Nomura K, Yamazaki N, Shintani T, Himi T. Telefitting of Nucleus Cochlear Implants: A Feasibility Study. Am J Audiol 2021; 30:16-21. [PMID: 33555935 DOI: 10.1044/2020_aja-20-00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Purpose This study aims to describe the recommended equipment and procedures required for successful telefitting, based on our experience, document and evaluate patient satisfaction with telefitting, and assess its clinical usefulness and address the existing issues. Method Twenty (seven children and 13 adults) individuals who lived far from cochlear implant (CI) centers and who were Nucleus CI users underwent conventional face-to-face fitting and telefitting. We examined the participants' subjective satisfaction and cost and time saved with the telefitting experience. Results The telefitting sessions lasted for an average of 16 min. Majority of the participants responded positively to the telefitting experience. Eighty percent (16/20) of the participants were satisfied with the new procedure, and 85% of them agreed to use telefitting again. Conclusions The results of our feasibility study suggest that telefitting was well received by CI users and is a viable alternative to local MAPping, even in young children with CIs. Although there are some limitations in terms of adaptability, telefitting could be an effective means of delivering CI service to remote locations.
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Affiliation(s)
- Kenichi Takano
- Department of Otolaryngology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Aya Kaizaki
- Department of Otolaryngology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Ayami Kimura
- Department of Otolaryngology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Kazuaki Nomura
- Department of Otolaryngology, Obihiro Kyokai Hospital, Hokkaido, Japan
| | - Norikazu Yamazaki
- Department of Otolaryngology, Hakodate Goryoukaku Hospital, Hokkaido, Japan
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Cabrera CI, Ning AY, Cai Y, D'Anza B. Systematic Review of Telehealth Cost Minimization for Patients and Health Systems in Otolaryngology. Laryngoscope 2020; 131:1741-1748. [PMID: 33355932 DOI: 10.1002/lary.29321] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/30/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE/HYPOTHESIS The COVID-19 pandemic has resulted in telehealth becoming commonplace in many health care fields. Telehealth benefits include improving access, decreasing costs, and elevating patient's experience. A review of cost minimization (CM) analyses was performed in order to explore scientific studies associated with integrating tele-otolaryngology in clinical practice. Our primary objective was to evaluate published literature for cost related to the implementation of telemedicine across otolaryngology, and to determine CM when compared to in-person visits. STUDY DESIGN Systematic Literature Review. METHODS We performed a systematic review using PubMed, EMBASE, and Cochrane in May 2020, to identify studies with a cost analysis of tele-otolaryngology care. Inclusion criteria focused on articles citing CM data from telehealth services. Literature quality was assessed using the MINORS scoring system. RESULTS From 380 original articles screened only nine evaluated cost in otolaryngology. CM in the US ranged from $68 to $900 per visit. Cost was evaluated in general otolaryngology, sleep medicine, otology, and head and neck cancer surgery, the latter had the most benefit. The most common types of telehealth visits were routine follow-up and screening. Data were insufficient for meta-analysis. CONCLUSIONS Telemedicine has been trialed across various otolaryngology subspecialties; its incorporation is projected to have a meaningful impact on access to specialty care. This research suggests that the delivery of virtual care reduces cost with the potential of increasing net revenue across multiple otolaryngology subspecialties. Further studies are needed to better discern the entirety of cost savings and the best settings for integration. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1741-1748, 2021.
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Affiliation(s)
- Claudia I Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Anne Y Ning
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Yida Cai
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Brian D'Anza
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
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Sharma S, Daniel M. Telemedicine in paediatric otorhinolaryngology: Lessons learnt from remote encounters during the Covid19 pandemic and implications for future practice. Int J Pediatr Otorhinolaryngol 2020; 139:110411. [PMID: 33022557 DOI: 10.1016/j.ijporl.2020.110411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Covid19 has necessitated new methods of conducting outpatient consultations. At our institute, patient-facing paediatric ENT appointments were replaced with telemedical consultations. METHOD We performed a prospective analysis of the outcomes following telephone consultations with parents and describe our experience of remote consulting during a pandemic, and the possibilities for future applications of telemedicine in paediatric ENT. RESULTS 215 patients were appropriately referred to the paediatric ENT clinic, 65% of these patients were deemed suitable for remote telephone consultation. Following a telephone call, 50% did not need further ENT clinic management, most commonly due to being listed for surgery (20%) or discharged (18%). The treating consultant assessed 81% of phone consultations as being effective. When given the choice, patients reported that 29% would choose a telephone consultation whilst 43% preferred a face to face consultation. CONCLUSION Our experience has shown that there are areas of paediatric ENT that can be streamlined effectively by substituting face to face consultations with telephone consultations. However, prospective evaluation of these remote contacts suggest that telephone consultations are not a panacea and cannot be indiscriminately applied to all. Instead, the strategies to take forwards into a post Covid19 practice are vetting of referrals, individualised treatment plans, and giving patients a choice.
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Affiliation(s)
- Shradha Sharma
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.
| | - Mat Daniel
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
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21
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Belcher RH, Phillips J, Virgin F, Werkhaven J, Whigham A, Wilcox L, Wootten CT. Pediatric Otolaryngology Telehealth in Response to COVID-19 Pandemic: Lessons Learned and Impact on the Future Management of Pediatric Patients. Ann Otol Rhinol Laryngol 2020; 130:788-795. [PMID: 33238714 PMCID: PMC7691763 DOI: 10.1177/0003489420976163] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Since the start of the COVID-19 pandemic outpatient medicine has drastically been altered how it is delivered. This time period likely represents the largest volume of telehealth visits in the United States health care history. Telehealth presents unique challenges within each subspecialty, and pediatric otolaryngology is no different. This retrospective review was designed to evaluate our division of pediatric otolaryngology’s experience with telehealth during the COVID19 pandemic. Methods: This study was approved by the Institutional Review Board at Vanderbilt University Medical Center. All telehealth and face-to-face visits for the month of April 2020 completed by the Pediatric Otolaryngology Division were reviewed. A survey, utilizing both open-ended questions and Likert scaled questions was distributed to the 16 pediatric otolaryngology providers in our group to reflect their experience with telehealth during the 1-month study period. Results: In April, 2020 our outpatient clinic performed a total of 877 clinic visits compared to 2260 clinic visits in April 2019. A total of 769 (88%) were telehealth visits. Telemedicine with video comprised 523 (68%) and telephone only comprised 246 (32%). There were 0 telehealth visits in April 2019. Interpretive services were required in 9.3% (N = 211) clinic visits in April 2019 and 7.5% (N = 66) of clinic visits in April 2020. The survey demonstrated a significant difference (P < .00002) in provider’s anticipated telehealth experience (mean 3.94, 95% CI [3.0632, 4.8118] compared to their actual experience after the study period (mean 7.5, 95% CI [7.113, 7.887]. Conclusions: Despite low initial expectations for telehealth, the majority of our providers felt after 1 month of use that telehealth would continue to be a valuable platform post-pandemic clinical practice. Limited physical exam, particularly otoscopy, nasal endoscopy, and nasolaryngoscopy present challenges. However, with adequate information and preparation for the parents and for the physician some of the obstacles can be overcome.
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Affiliation(s)
- Ryan H Belcher
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - James Phillips
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Frank Virgin
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Jay Werkhaven
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Amy Whigham
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Lyndy Wilcox
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Christopher T Wootten
- Pediatric Otolaryngology - Head and Neck Surgery at Vanderbilt Children's Hospital, Nashville, TN, USA
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Incorporation of telemedicine by rhinologists: The COVID-19 pandemic and beyond. Am J Otolaryngol 2020; 41:102567. [PMID: 32920475 PMCID: PMC7264942 DOI: 10.1016/j.amjoto.2020.102567] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022]
Abstract
Objectives The current analysis queries rhinologists' attitudes about the use of telemedicine, including the degree to which it has impacted practice patterns during the COVID-19 pandemic. Our objective was to survey rhinologists and understand the extent to which telemedicine serves as a rejoinder to in-person consultation: appreciation of relevant factors may be important in planning for present and future considerations. Methods A 14-question anonymous survey sent out to the American Rhinologic Society (ARS) membership in April 2020. It included demographic factors and detailed questions examining the extent of telemedicine use. Numerous topics including the degree of use, satisfaction with services, and utility of services were evaluated. Results There were 134 respondents. Most reported seeing ≤30% of typical in-person volume, with 14.8% not seeing any patients at all. 88.1% used telemedicine; 82.0% reported some level of satisfaction with telemedicine. The vast majority utilized platforms employing audio and video (83.3%), and a plurality reported spending 5–15 min on calls. Numerous reasons were cited for the use of telemedicine, including significant public health benefits amid the crisis (89.7%). Only 12.0% of respondents reported using telemedicine for hospital consultation. Conclusion Rhinologists have embraced telemedicine during the COVID-19 pandemic in an attempt to improve accessibility, patient satisfaction, and revenue stream. When utilized appropriately, this technology obviates the need for seeing at-risk patients and performing procedures such as nasal endoscopy. Only a minority of rhinologists was dissatisfied, viewing this as a temporary fix during the pandemic.
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Schafer A, Hudson S, Elmaraghy CA. Telemedicine in pediatric otolaryngology: Ready for prime time? Int J Pediatr Otorhinolaryngol 2020; 138:110399. [PMID: 33152987 PMCID: PMC7513831 DOI: 10.1016/j.ijporl.2020.110399] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/20/2020] [Indexed: 02/01/2023]
Abstract
The purpose of this paper is to explore the current literature on telemedicine in otolaryngology, focusing on the potential for telemedicine in the field and the major modalities available. Ultimately, the goal is to summarize telemedicine implementation in otolaryngology during the COVID-19 pandemic and potential long term applications. This paper analyzes a variety of studies that have evaluated the efficacy of different telemedicine approaches in otolaryngology, with commentary on what these results mean for the potential of telemedicine during the COVID-19 pandemic. Otolaryngology is well-suited for telemedicine, and this technology is viewed favorably by both patients and physicians. However, its application cannot be generalized to such a wide-ranging specialty. Furthermore, store and forward technology, which has been traditionally used to provide care to remote and underserved populations, and synchronous technology both have the potential to limit unnecessary in-person visits-ultimately keeping both patients and providers safe as social distancing continues.
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Affiliation(s)
- Austin Schafer
- The Ohio State University Wexner Medical Center, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA
| | - Sarah Hudson
- Nationwide Children's Hospital, Department of Pediatric Otolaryngology-Head and Neck Surgery, Columbus, OH, USA
| | - Charles A. Elmaraghy
- The Ohio State University Wexner Medical Center, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA,The Research Institute at Nationwide Children's Hospital, Center for Surgical Outcomes Research, Columbus, OH, USA,Nationwide Children's Hospital, Department of Pediatric Otolaryngology-Head and Neck Surgery, Columbus, OH, USA,Corresponding author. The Ohio State University Nationwide Children's Hospital, 700 Children's Drive, Columbus, Ohio, 43205, USA
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Ohlstein JF, Garner J, Takashima M. Telemedicine in Otolaryngology in the COVID-19 Era: Initial Lessons Learned. Laryngoscope 2020; 130:2568-2573. [PMID: 32740925 PMCID: PMC7435539 DOI: 10.1002/lary.29030] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
Objectives/Hypothesis The COVID‐19 pandemic has led to unprecedented global changes in the delivery of healthcare over a short period of time. With the implementation of shelter‐in‐place orders, otolaryngology clinic visits at our institution were transitioned to telemedicine. This change enabled the rapid characterization of the patients who accepted and declined telemedicine. Study Design Cross‐sectional analysis. Methods A review was conducted of 525 otolaryngology patients at a tertiary‐care referral center with scheduled visits requiring rescheduling to a future date or a telemedicine visit. Visit, demographic information, and reason for deferring telemedicine were collected for analysis. Results Seventy‐two percent of patients declined a telemedicine visit, with the most common reason being the lack of a physical exam (97%). There was an even distribution of demographics between those who accepted and declined visits. There was an association between declining telemedicine with older age (P = .0004) and otology visits (P = .0003), whereas facial plastics patients were more likely to accept (P < .0001). Patients scheduled earlier during the pandemic were more likely to accept a visit with a median of 28 days from onset of shelter‐in‐place orders versus 35 for those who declined (P < .0001). Conclusions We describe our initial experience with a transition to telemedicine, where the majority of patients would decline a virtual visit due to the lack of a physical exam. Although the future remains uncertain, telemedicine will continue to play a vital role in healthcare delivery. We believe that understanding our patient base gives critical insights that will help guide and improve virtual care to meet patients' needs. Level of Evidence 4 Laryngoscope, 130:2568–2573, 2020
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Affiliation(s)
- Jason F Ohlstein
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, Texas, U.S.A
| | - Jordan Garner
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Masayoshi Takashima
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, U.S.A
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25
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Ning AY, Cabrera CI, D'Anza B. Telemedicine in Otolaryngology: A Systematic Review of Image Quality, Diagnostic Concordance, and Patient and Provider Satisfaction. Ann Otol Rhinol Laryngol 2020; 130:195-204. [PMID: 32659100 DOI: 10.1177/0003489420939590] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Telemedicine allows for the remote delivery of patient care and has been found to have a wide range of uses in otolaryngology. In order to achieve best practices in telemedicine, a platform must be effective and both patients and providers must be satisfied with the use of technology. As telemedicine becomes more widely used in otolaryngology clinics, particularly in the face of the current COVID-19 pandemic, it is important to assess its applicability in this field. The goal of this study was to evaluate existing literature on telemedicine and assess overall image quality, diagnostic concordance, and patient and provider satisfaction with telemedicine technologies. METHODS A systematic review was conducted on PubMed and MEDLINE according to the PRISMA 2009 guidelines for articles from 1982 to 2019 relating to telemedicine in otolaryngology. English language studies with primary or secondary endpoints pertaining to image quality, diagnostic concordance, or patient or provider satisfaction were included. Descriptive studies, editorials, and literature reviews were excluded. RESULTS A total of 32 studies were included in our review. Studies assessing imaging quality and diagnostic concordance reported adequate results but with some heterogeneity. Patient and provider satisfaction were consistently high. CONCLUSIONS The literature supports telemedicine delivery of otorhinolaryngologic care as having achieved high rates of patient and provider satisfaction with adequate image quality and heterogeneity in diagnostic concordance. Variability in diagnostic accuracy was reported, but appears improved given proper clinical context. More standardized studies are needed specific to telemedicine in the field of otolaryngology.
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Affiliation(s)
- Anne Y Ning
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Claudia I Cabrera
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brian D'Anza
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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26
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Go BC, Brewster R, Patel R, Rajasekaran K. Using Telemedicine and Infographics for Physician-Guided Home Drain Removal. OTO Open 2020; 4:2473974X20933566. [PMID: 32548544 PMCID: PMC7273559 DOI: 10.1177/2473974x20933566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 12/27/2022] Open
Abstract
Objective Measures to decrease hospital length of stay and outpatient visits are
crucial during the coronavirus disease 2019 (COVID-19) pandemic.
Physician-guided home drain removal presents a potential opportunity for
mitigating viral spread and transmission. Methods A prospective case series on patients undergoing major head and neck surgery
with Jackson-Pratt drain placement was conducted. Patients were shown an
infographic detailing drain care and removal at preoperative assessment and
prior to discharge. At a 1-week follow-up telemedicine visit, patients were
instructed to remove the drain under physician guidance. Patients were
assessed 7 days after to determine complication rate and satisfaction. Results Twenty-five patients were enrolled with 100% patients undergoing successful
drain removal at home with caregiver support. There were no complications
reported at the 7-day postdrain removal time point, and overall patient
satisfaction was high. Discussion Infographics and telemedicine are 2 synergistic strategies to guide safe and
effective home drain removal. Implications for Practice This study demonstrates how telemedicine and an infographic can be
effectively used in physician-guided home drain removal. During a time like
the COVID-19 pandemic, innovative measures are necessary to curb
transmission and infection rates. We propose a unique and replicable yet
safe solution to limit unnecessary exposure and encourage other surgical
providers to adopt a similar strategy.
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Affiliation(s)
- Beatrice C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Brewster
- Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | - Risha Patel
- Drexel University, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Layfield E, Triantafillou V, Prasad A, Deng J, Shanti RM, Newman JG, Rajasekaran K. Telemedicine for head and neck ambulatory visits during COVID-19: Evaluating usability and patient satisfaction. Head Neck 2020; 42:1681-1689. [PMID: 32476228 PMCID: PMC7300847 DOI: 10.1002/hed.26285] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In light of the COVID-19 pandemic, there has been a rapid increase in telemedicine visits. Otolaryngology patient satisfaction with these visits has not yet been extensively studied using a validated survey. METHODS All patients who had telemedicine visits with three head and neck surgeons, by phone or video-based platform, between March 25, 2020 and April 24, 2020. Retrospective chart reviews were conducted to determine demographic, disease, and treatment information. Patients who had a video visit were contacted by telephone and, if they could be reached and consented, were administered the telehealth usability questionnaire (TUQ). RESULTS Hundred surveys were completed. The average score across all questions was 6.01 on a scale from 1 to 7, where 7 indicated the highest level of patient agreement. The highest scores were for questions related to satisfaction with telehealth (6.29), while the lowest were related to reliability (4.86). CONCLUSIONS Patients are generally highly satisfied with telemedicine.
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Affiliation(s)
- Eleanor Layfield
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vasiliki Triantafillou
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aman Prasad
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jie Deng
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rabie M Shanti
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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28
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Urban MJ, Wojcik C, Eggerstedt M, Jagasia AJ. Rural-Urban Disparities in Otolaryngology: The State of Illinois. Laryngoscope 2020; 131:E70-E75. [PMID: 32249932 DOI: 10.1002/lary.28652] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/24/2020] [Accepted: 02/29/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS To highlight rural-urban disparities in otolaryngology, and to quantify the disparities in access to otolaryngology specialist care across Illinois. Several studies across disciplines have shown increased prevalence and severity of disease in rural communities, relative to their urban counterparts. There is very little published quantifying a disparity in rural access to otolaryngologists. STUDY DESIGN Population study. METHODS Counties in Illinois were classified based on urbanization level on a scale from I (most urban) to VI (least urban) using the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification scheme. The six urbanization levels include four metropolitan (I-IV) and two nonmetropolitan levels (V and VI). The name and practice location of all registered otolaryngologists in Illinois were collected using the American Academy of Otolaryngology website (ENTnet.org). Population data were recorded from the most recent US Census (2010). RESULTS Two hundred seventy-eight academy-registered otolaryngologists were identified in Illinois. One hundred fifty-one of these providers were located in a single county categorized as a level I by the NCHS scheme. There are over 18,000 square miles and 600,000 persons living in NCHS level VI counties in Illinois with zero registered otolaryngologists. Overall, metropolitan counties (I-IV) averaged 1.32 otolaryngologists per 100,000 population, whereas nonmetropolitan counties (V and VI) averaged 0.46 otolaryngologists per 100,000 (P < .01). CONCLUSIONS There is a paucity of academy-certified otolaryngologists with primary practice locations in rural counties of Illinois. There is a significant rural population and massive land area with limited spatial access to otolaryngologic specialist care. LEVEL OF EVIDENCE NA Laryngoscope, 131:E70-E75, 2021.
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Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois;, U.S.A
| | | | - Michael Eggerstedt
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois;, U.S.A
| | - Ashok J Jagasia
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois;, U.S.A
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Greiwe J. Using Telemedicine in a Private Allergy Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2560-2567. [PMID: 31336177 DOI: 10.1016/j.jaip.2019.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/28/2019] [Accepted: 07/11/2019] [Indexed: 11/29/2022]
Abstract
As technology improves and telehealth companies continue to innovate, the ways in which physicians can provide care for their patients are constantly expanding. Providing quality health care is no longer constrained by local commutes and a brick-and-mortar footprint, but instead can be provided at a local, regional, and national level in ways that were not feasible in the past. The possibilities are endless as we enter a brave new world where medicine and technology meet. But what exactly is telemedicine and how can it be incorporated into a busy clinical allergy practice? What are the barriers to entry and how can telemedicine be used to enhance patient care by providing more options and driving revenue all at the same time? At its core, telemedicine is simply the remote treatment of patients using telecommunication tools such as telephones, smartphones, and computers. Of course, the implementation of this basic concept is much more nuanced and complex, with virtual visits acting as the sounding board for a host of additional synergistic health applications including wearable devices and mobile apps. This new model of health care delivery has the potential to uproot but at the same time enhance the conventional doctor-patient relationship, and if used correctly address many of the challenges that have historically plagued health care. Telemedicine and telehealth technologies can be used to strengthen medical services and overcome many of the barriers that have previously existed by providing safe, accessible, cost-effective, and convenient health care at the touch of a button.
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Affiliation(s)
- Justin Greiwe
- Bernstein Allergy Group, Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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