Case study: providing evidence-based behavioral and nutrition treatment to a toddler with cystic fibrosis and multiple food allergies via telehealth

Telemedicine and remote monitoring in cystic fibrosis

PURPOSE OF REVIEW

Guidelines for cystic fibrosis (CF) care recommend multidisciplinary teams see patients at least quarterly with frequent measurement of spirometry and collection of respiratory cultures. This can be burdensome for people with CF, particularly if they live far from a specialized care center. This has led to an interest in telehealth coupled with remote monitoring. We review the recent literature on these topics for people with CF.

RECENT FINDINGS

The COVID-19 pandemic accelerated a move toward remote delivery of CF care and multiple recent publications have reported on the feasibility of telehealth, remote spirometry, remote collection of respiratory cultures, adherence monitoring, cough assessment, symptom monitoring and activity tracking. Useful data can be obtained and both clinicians and patients have favorable opinions about remote delivery of healthcare, though the impact on clinical outcomes is not yet known.

SUMMARY

Telehealth and remote monitoring for people with CF is feasible and has grown in use, though it is too early to know how prominently these approaches will fit into routine care for CF.

Telehealth and virtual health monitoring in cystic fibrosis

PURPOSE OF REVIEW

At many institutions, the Covid-19 pandemic made it necessary to rapidly change the way services are provided to patients, including those with cystic fibrosis (CF). The purpose of this review is to explore the past, present and future of telehealth and virtual monitoring in CF and to highlight certain challenges/considerations in developing such services.

RECENT FINDINGS

The Covid-19 pandemic has proven that telehealth and virtual monitoring are a feasible means for safely providing services to CF patients when traditional care is not possible. However, both telehealth and virtual monitoring can also provide further support in the future in a post-covid era through a hybrid-model incorporating traditional care, remote data collection and sophisticated platforms to manage and share data with CF teams.

SUMMARY

We provide a detailed overview of telehealth and virtual monitoring including examples of how paediatric and adult CF services adapted to the need for rapid change. Such services have proven popular with people with CF meaning that co-design with stakeholders will likely improve systems further. In the future, telehealth and virtual monitoring will become more sophisticated by harnessing increasingly powerful technologies such as artificial intelligence, connected monitoring devices and wearables. In this review, we harmonise definitions and terminologies before highlighting considerations and limitations for the future of telehealth and virtual monitoring in CF.

Telehealth in cystic fibrosis: a systematic review

We conducted a systematic review of the use of telehealth in people with Cystic Fibrosis (CF). The studies reviewed were of adults and children with CF, and incorporated telehealth for monitoring symptoms, assessing adherence to prescribed therapies or providing a therapeutic intervention. Searches of four electronic databases returned 293 references. Eight studies met the inclusion criteria. Variability in study design and outcome measures precluded meta-analysis. Seven studies assessed telemonitoring feasibility for patient usability and acceptance, or for physiological monitoring. Two studies were randomised controlled trials, although only one showed differences in outcome between the intervention and usual care with improved spirometry stability and significantly increased antibiotic use in the intervention group. In four studies participants were asked to transmit data on spirometry (FEV(1)) or symptoms. Participant non-compliance with data reporting ranged from 43-63%. Generally, participants reported being able to use the required technology. There is insufficient evidence to reach a firm conclusion about the benefits of telehealth in people with CF, but it remains a promising area for future investigation.

Health information technology to facilitate communication involving health care providers, caregivers, and pediatric patients: a scoping review

BACKGROUND

Pediatric patients with health conditions requiring follow-up typically depend on a caregiver to mediate at least part of the necessary two-way communication with health care providers on their behalf. Health information technology (HIT) and its subset, information communication technology (ICT), are increasingly being applied to facilitate communication between health care provider and caregiver in these situations. Awareness of the extent and nature of published research involving HIT interventions used in this way is currently lacking.

OBJECTIVE

This scoping review was designed to map the health literature about HIT used to facilitate communication involving health care providers and caregivers (who are usually family members) of pediatric patients with health conditions requiring follow-up.

METHODS

Terms relating to care delivery, information technology, and pediatrics were combined to search MEDLINE, EMBASE, and CINAHL for the years 1996 to 2008. Eligible studies were selected after three rounds of duplicate screening in which all authors participated. Data regarding patient, caregiver, health care provider, HIT intervention, outcomes studied, and study design were extracted and maintained in a Microsoft Access database. Stage of research was categorized using the UK's Medical Research Council (MRC) framework for developing and evaluating complex interventions. Quantitative and qualitative descriptive summaries are presented.

RESULTS

We included 104 eligible studies (112 articles) conducted in 17 different countries and representing 30 different health conditions. The most common conditions were asthma, type 1 diabetes, special needs, and psychiatric disorder. Most studies (88, 85%) included children 2 to 12 years of age, and 73 (71%) involved home care settings. Health care providers operated in hospital settings in 96 (92%) of the studies. Interventions featured 12 modes of communication (eg, Internet, intranets, telephone, video conferencing, email, short message service [SMS], and manual downloading of information) used to facilitate 15 categories of functions (eg, support, medication management, education, and monitoring). Numerous patient, caregiver, and health care relevant outcomes have been measured. Most outcomes concerned satisfaction, use, usability, feasibility, and resource use, although behavior changes and quality of life were also reported. Most studies (57 studies, 55%) were pilot phase, with a lesser proportion of development phase (24 studies, 23%) and evaluation phase (11 studies, 11%) studies. HIT interventions addressed several recurring themes in this review: establishing continuity of care, addressing time constraints, and bridging geographical barriers.

CONCLUSIONS

HIT used in pediatric care involving caregivers has been implemented differently in a range of disease settings, with varying needs influencing the function, form and synchronicity of information transfer. Although some authors have followed a phased approach to development, evaluation and implementation, a greater emphasis on methodological standards such as the MRC guidance for complex interventions would produce more fruitful programs of development and more useful evaluations in the future. This review will be especially helpful to those deciding on areas where further development or research into HIT for this purpose may be warranted.

The efficacy of adherence interventions for chronically ill children: a meta-analytic review

OBJECTIVES

To provide quantitative information about the overall effectiveness of adherence interventions to improve adherence and health outcomes for children with chronic illnesses. To evaluate statistically the potential moderators.

METHODS

A meta-analysis was performed on 71 adherence intervention studies.

RESULTS

Weighted-mean effect size (ES) across all the adherence outcomes for group design studies was in the medium range (mean d = 0.58) and for single-subject design studies was in the large range (mean d = 1.44). The weighted mean ES across all health outcome measures for studies using group designs was in the medium range (mean d = 0.40) and for studies using single-subject designs was in the large range (mean d = 0.74).

CONCLUSIONS

Adherence interventions for children with chronic illnesses effectively increase adherence and result in some positive health benefits. Intervention and methodological variables had significant impact on ESs. High levels of heterogeneity characterized the data.