Telephone Consultation as a Substitute for Routine Out-patient Face-to-face Consultation for Children With Inflammatory Bowel Disease: Randomised Controlled Trial and Economic Evaluation

Mobile monitoring system detects the disease activity pattern and shows the association with clinical outcomes in patients with newly diagnosed Crohn's disease

We aimed to determine whether Crohn's disease (CD) activity patterns assessed via a web-based symptom diary can help predict clinical outcomes in patients with newly diagnosed CD. Patients diagnosed with CD within the preceding 3 months were prospectively enrolled at four tertiary centers. All patients recorded their symptoms on a website using a smartphone at least once a week. The index outcomes were disease-related admission and surgery during follow-up. The disease activity from enrollment to outcome or last follow-up was reviewed for pattern analysis. Cox regression analysis was used to identify the predictors of disease outcomes. A total of 102 patients were enrolled. During a median follow-up period of 42 months, 25 (24.5%) and 6 (5.9%) patients required admission and surgery, respectively. Poor activity pattern was an independent predictor of disease-related hospitalization (adjusted hazard ratio [aHR], 3.96; 95% confidence interval [CI] 1.5-10.45; p = 0.005). A poor activity pattern (aHR, 19.48; 95% CI 1.86-203.95; p = 0.013) and female sex (aHR, 11.28; 95% CI 1.49-85.01; p = 0.018) were found to be independent predictors of bowel resection. CD disease activity patterns monitored through the mobile monitoring system may help predict clinical outcomes, such as disease-related hospitalization and surgery, in patients with newly diagnosed CD.

Examining the Effectiveness of Telephone Clinics: A Review of a Telephone Foot and Ankle Orthopaedic Clinic in a District General Hospital in the United Kingdom

INTRODUCTION

Since the outbreak of COVID-19, significant value has been placed on preventative methods for pathogen spread. One such method is the use of telemedicine via telephone clinics (TC). This article is designed to study TC in a District General Hospital in the United Kingdom.

AIMS

This clinical audit aims to evaluate the use of a TC in the United Kingdom and assess its effectiveness. It also aims to assess the use of a clinician-led triaging system to select patients who would receive subsequent telephone follow-ups (TFU).

METHODOLOGY

Two cycles were conducted. The first cycle was conducted in 2020 and the second cycle in 2022. In between the two cycles, a clinician-led triage system was implemented to reduce the number of patients being called back for a face-to-face (FTF) appointment. Data was collected regarding the outcomes of the appointments and compared between the two cycles. Chi-squared test statistical test was employed with a p-value < 0.05 deeming significance.

RESULTS

Overall, more discharges were made for 2022 outcomes compared to 2020 outcomes (30% vs 19%; p = 0.03) after employing the clinician-led triage. The number of patients listed for a TFU increased when comparing the 2020 versus 2022 datasets (21% vs 12%; p = 0.026), and the overall number of patients not attending appointments decreased when comparing the 2020 versus 2022 datasets (9% vs 17%; p = 0.033).

CONCLUSION

This article shows that for this particular clinic, an orthopaedic clinician-led triaging system allows for a greater number of patients to be discharged, lessened need for FTF consultations, and increased adherence to appointments by patients. However, much work is yet to be done concerning the long-term consequences and issues of rolling out nationwide telemedicine.

Barriers to and requirements for a successful transition in inflammatory bowel disease from pediatric to adult care in Greece

Background

The incidence of pediatric-onset inflammatory bowel disease (IBD) is rising, while the relapsing and often severe nature of IBD, and its impact on emotional and pubertal development and social maturation underline the need for a successful transition from pediatric to adult care.

Methods

A web-based survey was distributed via the Hellenic Group for the Study of IBD, the Hellenic Society of Gastroenterology Department of North Greece, and the Hellenic Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

Results

The questionnaire was answered by 98 individuals (78 adult and 20 pediatric gastroenterologists, out of 357 and 30, respectively). The response rate was 25.3%. A higher response rate was found among pediatric (66.6%) vs. adult gastroenterologists 21.8% (P<0.001). Pediatric gastroenterologists believed that the appropriate age for transition was either 16-17 or 17-18 years, whereas 59% of the adult gastroenterologists chose the age group of 16-17 years. Both adult and pediatric gastroenterologists stated that the most significant initiators for a successful transition process were cognitive maturity and patients' ability to manage their disease independently. The lack of communication and collaboration between pediatric and adult gastroenterologists was the main barrier to the transition process, as identified by adult gastroenterologists (27.7%). In contrast, 43.5% of pediatric gastroenterologists suggested that differences in the follow up of patients with IBD between pediatric and adult clinics were the main restrictions.

Conclusion

These results highlight the need for a transitional education program for pediatric IBD patients, and the importance of improving collaboration among adult and pediatric gastroenterologists.

Leveraging Virtual Technology to Conduct Clinical Trials in Inflammatory Bowel Disease

Clinical trials have led to major advances in inflammatory bowel disease (IBD) care over the last few decades, yet in that time most clinical trial protocols in IBD have remained markedly the same. Many IBD protocols often still require face-to-face visits and monitoring, hospital-based medication administration, paper-based forms and questionnaires, and short follow-up periods resulting in limited long-term data. These factors have recently been recognized as likely contributors to the low recruitment and lack of diversity of participants across clinical trials in IBD. However, with increasing technological advances, there is now an opportunity for improvement. This article assesses a range of virtual innovations for how they may offer digital solutions to challenges currently encountered in IBD clinical trials. Such solutions include consideration for increasing patient diversity, digital invitation, remote consent and recruitment, virtual visits, remote patient monitoring and data collection, remote medication delivery and administration, remote clinical trial monitoring, and routinely collected health data for long-term follow-up. Adoption of virtual technology may drive the field toward patient centricity and more efficient trial protocols to allow for a new era in IBD clinical trials.

The Cost Impact of Telehealth Interventions in Pediatric Surgical Specialties: A Systematic Review

BACKGROUND

Telehealth is a rapidly expanding care modality in the United States. Pediatric surgical patients often require complex care which can incur significant expenses, some of which may be alleviated by telehealth. We performed a systematic review comparing telehealth and in-person visits, and telehealth's impacts on the cost of healthcare across pediatric surgical specialties.

METHODS

A systematic review was performed using the following databases: PubMed (MEDLINE), Scopus (Elsevier), and CINAHL (EBSCOHost), searched from inception to July 10th, 2022. Studies were included per the following criteria: (1) investigated a telehealth intervention for pediatric surgical care and (2) provided some metric of telehealth cost compared to an in-person visit. Non-English or studies conducted outside of the U.S. were excluded.

RESULTS

Fourteen manuscripts met inclusion criteria and presented data on 7992 visits, including patients with a weighted average age of 7.5 ± 3.5 years. Most (11/14) studies used telehealth in a synchronous, or "real-time" context. Of the studies which calculated dollar cost savings for telehealth visits compared to in-person appointments we found a substantial range of savings per visit, from $48.50 to $344.64. Cost savings were frequently realized in terms of reduced travel expenditures, lower opportunity costs (e.g. lost wages), and decreased hospital labor requirements.

CONCLUSIONS

This review suggests that telehealth provides cost incentives to pediatric surgical care in many scenarios, including post-operative visits and some routine clinic visits. Future work should focus on standardizing the metrics by which cost impacts are analyzed and detailing which visits are most appropriately facilitated by telehealth.

LEVEL OF EVIDENCE

V.

Patients' experience of teleconsultations in the UK

BACKGROUND

Teleconsultations were introduced for cancer surgery follow-up to ease pressure on hospital services and facilitate patients' access to those services. There is limited evidence on patients' perceptions of this swift shift in service provision.

AIMS

The purpose of this qualitative systematic review was to explore patient experiences of teleconsultations within NHS cancer surgery follow-up services to better understand patient perceptions, satisfaction and acceptability of teleconsultations within cancer services.

METHODS

Medline, Embase, PubMed and Google Scholar were searched up to 1 July 2022. Qualitative studies were synthesised using the Braun and Clarke framework.

FINDINGS

There were three overarching themes: accessibility; patient experience; and consultation.

CONCLUSION

Teleconsultations were widely accepted among cancer surgical patients. However, there were reports of a lack of rapport building and emotional support because of the absence of visual cues and patient camaraderie.

Remote care through telehealth for people with inflammatory bowel disease

BACKGROUND

People with inflammatory bowel disease (IBD) require intensive follow-up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web-based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID-19) pandemic, which led to increased self- and remote-management.

OBJECTIVES

To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness.

SEARCH METHODS

On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web-based and telephone-based. Web-based monitoring versus usual care Twelve studies compared web-based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web-based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI -0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta-analysis on flare-ups. Web-based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare-ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web-based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare-ups or relapses in adults with CD (MD 0.00 events, 95% CI -0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare-ups in a paediatric population. Web-based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare-ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web-based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI -0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web-based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI -0.63 to 0.63), although the evidence is very uncertain. When we meta-analysed dichotomous data from two studies on adults, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web-based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost- or time-effectiveness. The certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

The evidence in this review suggests that web-based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare-ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web-based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web-based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web-based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow-up or investigate under-reported outcomes or populations. Studies with a clearer definition of web-based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

Exploring the use of digital technology to deliver healthcare services with explicit consideration of health inequalities in UK settings: A scoping review

Objective

To map and explore existing evidence on the use of digital technology to deliver healthcare services with explicit consideration of health inequalities in UK settings.

Methods

We searched six bibliographic databases, and the National Health Service (NHS) websites of each UK nation (England, Scotland, Wales, Northern Ireland). Restrictions were applied on publication date (2013-2021) and publication language (English). Records were independently screened against eligibility criteria by pairs of reviewers from the team. Articles reporting relevant qualitative and/or quantitative research were included. Data were synthesised narratively.

Results

Eleven articles, reporting data from nine interventions, were included. Articles reported findings from quantitative (n = 5), qualitative (n = 5), and mixed-methods (n = 1) studies. Study settings were mainly community based, with only one hospital based. Two interventions targeted service users, and seven interventions targeted healthcare providers. Two studies were explicitly and directly aimed at (and designed for) addressing health inequalities, with the remaining studies addressing them indirectly (e.g. study population can be classed as disadvantaged). Seven articles reported data on implementation outcomes (acceptability, appropriateness, and feasibility) and four articles reported data on effectiveness outcomes, with only one intervention demonstrating cost-effectiveness.

Conclusions

It is not yet clear if digital health interventions/services in the UK work for those most at risk of health inequalities. The current evidence base is significantly underdeveloped, and research/intervention efforts have been largely driven by healthcare provider/system needs, rather than those of service users. Digital health interventions can help address health inequalities, but a range of barriers persist, alongside a potential for exacerbation of health inequalities.

Role of Telemedicine in Inflammatory Bowel Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Telemedicine plays an important role in the management of inflammatory bowel disease (IBD), particularly during a pandemic such as COVID-19. However, the effectiveness and efficiency of telemedicine in managing IBD are unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to compare the impact of telemedicine with that of standard care on the management of IBD.

METHODS

We systematically searched the PubMed, Cochrane Library, EMBASE, Web of Science, and Scopus databases on April 22, 2020. Randomized controlled trials comparing telemedicine with standard care in patients with IBD were included, while conference abstracts, letters, reviews, laboratory studies, and case reports were excluded. The IBD-specific quality of life (QoL), disease activity, and remission rate in patients with IBD were assessed as primary outcomes, and the number of in-person clinic visits per patient, patient satisfaction, psychological outcome, and medication adherence were assessed as secondary outcomes. Review Manage 5.3 and Stata 15.1 were used for data analysis.

RESULTS

A total of 17 randomized controlled trials (2571 participants) were included in this meta-analysis. The telemedicine group had higher IBD-specific QoL than the standard care group (standard mean difference 0.18, 95% CI 0.01 to 0.34; P.03). The number of clinic visits per patient in the telemedicine group was significantly lower than that in the standard care group (standard mean difference -0.71, 95% CI -1.07 to -0.36; P<.001). Subgroup analysis showed that adolescents in the telemedicine group had significantly higher IBD-specific QoL than those in the standard care group (standard mean difference 0.42, 95% CI 0.15 to 0.69; I2=0; P.002), but there was no significant difference between adults in the 2 groups. There were no significant differences in disease activity, remission rate, patient satisfaction, depression, self-efficacy, generic QoL, and medication adherence outcomes between the telemedicine and standard care groups.

CONCLUSIONS

Telemedicine intervention showed a promising role in improving IBD-specific QoL among adolescents and decreased the number of clinic visits among patients with IBD. Further research is warranted to identify the group of patients with IBD who would most benefit from telemedicine.

Digital Health Technologies for Remote Monitoring and Management of Inflammatory Bowel Disease: A Systematic Review

INTRODUCTION

Digital health technologies may be useful tools in the management of chronic diseases. We performed a systematic review of digital health interventions in the management of patients with inflammatory bowel diseases (IBD) and evaluated its impact on (i) disease activity monitoring, (ii) treatment adherence, (iii) quality of life (QoL) measures, and/or (iv) health care utilization.

METHODS

Through a systematic review of multiple databases through August 31, 2020, we identified randomized controlled trials in patients with IBD comparing digital health technologies vs standard of care (SoC) for clinical management and monitoring and reporting impact on IBD disease activity, treatment adherence, QoL, and/or health care utilization or cost-effectiveness. We performed critical qualitative synthesis of the evidence supporting digital health interventions in patients with IBD and rated certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Overall, we included 14 randomized controlled trials (median, 98 patients; range 34-909 patients; follow-up <12 months) that compared web-based interventions, mobile applications, and different telemedicine platforms with SoC (clinic-based encounters). Although overall disease activity and risk of relapse were comparable between digital health technologies and SoC (very low certainty of evidence), digital health interventions were associated with lower rate of health care utilization and health care costs (low certainty of evidence). Digital health interventions did not significantly improve patients' QoL and treatment adherence compared with SoC (very low certainty of evidence). Trials may have intrinsic selection bias due to nature of digital interventions.

DISCUSSION

Digital health technologies may be effective in decreasing health care utilization and costs, though may not offer advantage in reducing risk of relapse, QoL, and improving treatment adherence in patients with IBD. These techniques may offer value-based care for population health management.

Promoting psycho-social wellbeing for engaging inflammatory bowel disease patients in their care: an Italian consensus statement

BACKGROUND

Inflammatory bowel diseases (IBD) are remitting and relapsing diseases that mainly interest the gastrointestinal tract. IBD is associated with a condition of psycho-social discomfort that deeply compromises the quality of life and the competence of patient to be fully engaged in their self-management. As a consequence, effective care of IBD patients should include not only medical but also psychological support in order to improve patients' wellbeing. Although this, to date there is no standardized approach to promote psychological wellbeing of IBD patients in order to improve the perception of the quality of the care. To fill this gap, a consensus conference has been organized in order to define the psychosocial needs of IBD patients and to promote their engagement in daily clinical practice. This paper describes the process implemented and illustrates the recommendations deriving from it, which focus on the importance of a multidisciplinary approach in IBD management.

RESULTS

The consensus conference has been organized in three phases: (1) literature review about life experiences, engagement, and psychosocial needs of IBD patients; (2) workshops with IBD experts and patients' representatives; (3) drafting of statements and voting. Seventy-three participants were involved in the consensus conference, and sixteen statements have been voted and approved during the consensus process.

CONCLUSIONS

The main conclusion is the necessity of the early detection of - and, in case of need, intervention on- psycho-social needs of patients in order to achieve patient involvement in IBD care.

Telemedicine and Integrated Multidisciplinary Care for Pediatric IBD Patients: A Review

The global COVID-19 pandemic brought with it an unprecedented, widespread implementation of telemedicine services, requiring pediatric inflammatory bowel disease (IBD) providers to shift in-person clinic visits to a virtual platform. With the passing of the one-year anniversary of the global pandemic, telemedicine continues to be offered and utilized. Although it remains unclear as to the extent to which telemedicine services will be used in the future, it is critical to understand how integrated multidisciplinary treatment-the standard of care in pediatric IBD-is delivered through a virtual platform. This paper provides an overview of the existing literature examining integrated multidisciplinary care for pediatric IBD provided via telemedicine. The author also presents one integrated multidisciplinary IBD program's response to the global pandemic and subsequent transition to telemedicine. Challenges around implementation and directions for future research in this area are also discussed.

Applying Telemedicine to Multidisciplinary Pediatric Inflammatory Bowel Disease Care

Multidisciplinary care is essential to the delivery of comprehensive, whole-person care for children and adolescents with inflammatory bowel disease (IBD). Team members may include medical, psychosocial, and ancillary providers as well as patient and family advocates. There is significant variability in how this care is delivered from center to center, though prior to the COVID-19 pandemic, most care occurred during in-person visits. At the onset of the pandemic, medical systems world-wide were challenged to continue delivering high quality, comprehensive care, requiring many centers to turn to telemedicine technology. The aim of this manuscript is to describe the process by which we converted our multidisciplinary pediatric and adolescent IBD visits to a telemedicine model by leveraging technology, a multidisciplinary team, and quality improvement (QI) methods. Finally, we put our experience into context by summarizing the literature on telemedicine in IBD care, with a focus on pediatrics and multidisciplinary care.

A telephone assessment and advice service within an ED physiotherapy clinic: a single-site quality improvement cohort study

BACKGROUND

In response to issues with timely access and high non-attendance rates for Emergency Department (ED) physiotherapy, a telephone assessment and advice service was evaluated as part of a quality improvement project. This telehealth option requires minimal resources, with the added benefit of allowing the healthcare professional streamline care. A primary aim was to investigate whether this service model can reduce wait times and non-attendance rates, compared to usual care. A secondary aim was to evaluate service user acceptability.

METHODS

This was a single-site quality improvement cohort study that compares data on wait time to first physiotherapy contact, non-attendance rates and participant satisfaction between patients that opted for a service based on initial telephone assessment and advice, versus routine face-to-face appointments. 116 patients were referred for ED physiotherapy over the 3-month pilot at the ED and out-patient physiotherapy department, XMercy University Hospital, Cork, Ireland. 91 patients (78%) opted for the telephone assessment and advice service, with 40% (n=36) contacting the service. 25 patients (22%) opted for the face-to-face service. Data on wait time and non-attendance rates was gathered using the hospital data reporting system. Satisfaction data was collected on discharge using a satisfaction survey adapted from the General Practice Assessment Questionnaire. Independent-samples t-test or Mann Whitney U Test was utilised depending on the distribution of the data. For categorical data, Chi-Square tests were performed. A level of significance of p ≤ 0.05 was set for this study.

RESULTS

Those that contacted the telephone assessment and advice service had a significantly reduced wait time (median 6 days; 3-8 days) compared to those that opted for usual care (median 35 days; 19-39 days) (p ≤ 0.05). There was no significant between-group differences for non-attendance rates or satisfaction.

CONCLUSION

A telephone assessment and advice service may be useful in minimising delays for advice for those referred to ED Physiotherapy for musculoskeleltal problems. This telehealth option appears to be broadly acceptable and since it can be introduced rapidly, it may be helpful in triaging referrals and minimising face-to-face consultations, in line with COVID-19 recommendations. However, a large scale randomised controlled trial is warranted to confirm these findings.

Changing to remote management of a community heart failure population during COVID-19 - Clinician and patient perspectives'

BACKGROUND

The COVID pandemic has challenged the traditional methods used in care of patients with heart failure (HF). Remote management of HF patients has been recommended in order to maintain routine standards of care, but satisfaction with this platform of care is unknown. We set out to address the physician and patient opinion of remote management of HF during COVID-19.

METHODS AND RESULTS

An observational report of the use of a Structured Telephonic assessment (STA) in stable outpatient HF patients. Physician grading of the STA was complemented by 100 randomly chosen patients to ascertain patient satisfaction and comment. 278 patients underwent a STA. Patient preference for STA was noted in 66%. Convenience was the single most cited reason for this preference (83.3%). The STA was deemed satisfactory by clinicians in 67.6%. The two-leading reasons for clinician dissatisfaction were data gaps providing a barrier to titration (55.6%) and need for clinical exam (18.9%). The annual review appointment visit subtype possessed the highest levels of satisfaction congruence amongst both clinicians and patients.

CONCLUSION

In summary, this report demonstrates reasonable patient / physician satisfaction with STA, and provides some direction on how this care platform might be sustained beyond the COVID crisis.

Comparing video consultation and telephone consultation at the outpatient clinic of a tertiary referral centre: patient and provider benefits

Objectives

Telephone consultations are frequently used in the outpatient setting in order to avoid unnecessary travel and to reduce hospital visit-related costs for patients. However, they are limited by the absence of non-verbal communication in contrast to video consultation. Little is known considering the possible advantages of using video consultation in comparison to telephone consultation according to both patients and healthcare providers.

Methods

Patients with colorectal diseases were asked to choose between a telephone consultation or a video consultation for their next appointment at the outpatient clinic of a tertiary referral centre. Willingness to use video consultation, value of non-verbal communication, patient satisfaction, provider satisfaction and user friendliness of the video connection technology were measured using questionnaires.

Results

None of the included patients ever had a video consultation before with a healthcare provider. Nonetheless, 22/50 preferred a video consultation over a telephone consultation. Patients who preferred a video consultation underlined the benefits of providing visual feedback to both patients and healthcare providers. Moreover, healthcare providers felt they were better able to assess the patients’ healthcare condition.

Conclusion

For patients who value both verbal and non-verbal interaction and feel comfortable with the use of video consultation, video consultation is the preferred contact modality. Shared decision making should be used to choose the preferred interaction modality. For patients with low digital skills, support might be needed or video consultation may not be the preferred choice.

Children and young people with inflammatory bowel disease attend less school than their healthy peers

OBJECTIVE

Chronic diseases, such as inflammatory bowel disease (IBD), can impact negatively on education and social development. Examining the impact of IBD on school/college attendance for children and young people (CYP) is vital to provide targeted support to patients, families and schools.

METHODS

We performed a cross-sectional survey to determine the school/college attendance rates, the reasons for absence related to IBD and facilitators or barriers to school/college attendance. In a subset of patients followed up locally, we performed a detailed review of hospital attendance data to assess healthcare burden.

RESULTS

Two hundred and thirty-one questionnaires were given to CYP with IBD aged 5-17 years. Response rate was 74% (final sample 169). The median school/college attendance rate was 92.5%, significantly lower than all children in England (95.2%). 39.6% of children with IBD were persistently absent, defined nationally as missing 10% or more of school. Only five children (3%) had a 100% attendance record. Increasing age and use of monoclonal therapy were predictors of poor school attendance. Concerns about feeling unwell at school/college, access to toilets, keeping up with work and teachers' understanding of IBD are the main issues for CYP with IBD. There was a significant negative correlation between number of days in hospital and school attendance.

CONCLUSION

IBD has a significant impact on school/college attendance, with hospital attendance, disease burden and school difficulties being major factors. Employing strategies to minimise healthcare burden and developing a partnership between health and education to support children with IBD will serve to facilitate school/college attendance.

Stratification of inflammatory bowel disease outpatients by disease activity and risk of complications to guide out-of-hospital monitoring: a patient-centred quality improvement project

Background

Inflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support.

Design and strategy

In this large-scale quality improvement project at St Mark’s Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.

A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using ‘Plan-Do-Study-Act’ cycles within the ‘Model for Improvement’ framework and analysed data continuously using statistical process charts.

Results

Over 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days.

Conclusion

This is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation

By what measure should a policy maker choose between two mediums that deliver the same or similar message or service? Between, say, video consultation or a remote patient monitoring application (i.e. patient-facing digital health innovations) and in-person consultation? To answer this question, we sought to identify measures which are used in randomised controlled trials. But first we used two theories to frame the effects of patient-facing digital health innovations on - 1) transaction costs (i.e. the effort, time and costs required to complete a clinical interaction); and 2) process outcomes and clinical outcomes along the care cascade or information value chain, such that the 'value of information' (VoI) is different at each point in the care cascade or value chain. From the trials, we identified three categories of measures: outcome (process or clinical), satisfaction, and cost. We found that although patient-facing digital health innovations tend to confer much of their value by altering process outcomes, satisfaction, and transaction costs, these measures are inconsistently assessed. Efforts to determine the relative value of and choose between mediums of service delivery should adopt a metric (i.e. mathematical combination of measures) that capture all dimensions of value. We argue that 'value of information' (VoI) is such a metric - it is calculated as the difference between the 'expected utility' (EU) of alternative options. But for patient-facing digital health innovations, 'expected utility' (EU) should incorporate the probability of achieving not only a clinical outcome, but also process outcomes (depending on the innovation under consideration); and the measures of utility should include satisfaction and transaction costs; and also changes in population access to services, and health system capacity to deliver more services, which may result from reduction in transaction costs.

Continuous care education for patients with inflammatory bowel disease

Continuous nursing education for patients with inflammatory bowel disease (IBD) has positive influence in reducing clinical visits and medical costs, alleviating psychological stress, and improving their quality of life. This article reviews the forms and contents of continuing nursing education for patients with IBD.

Role for structured telephone clinics in paediatric gastroenterology: reflections, lessons and patient feedback

BACKGROUND

Telephone clinics have been established within our department to try and improve communication with families, limit waiting times and help face-to-face clinics run more efficiently. As part of the ongoing care needs for our patients and families it was felt important to determine if telephone clinics were meeting the needs of the young person and family as well as those of the health professional.

OBJECTIVE

To assess the effects of a structured consultant delivered telephone clinic.

METHOD

Data were collected regarding patients who had a consultant telephone appointment between July 2016 and March 2017. Data collected include demographics and appointment reason. An evaluation questionnaire was sent to all parent/carer(s).

RESULTS

25 clinics comprising 194 contacts, including 34 duplicate contacts. 120 questionnaires sent. 7/160 (4.3%) were new patients. The main contact reason was biopsy results after endoscopy (93/180; 52%). Failure to attend rate was significantly lower at 18/194 (9.2%) compared with failure to attend rate of 52/240 (21.6%) for a traditional clinic (p<0.001). 40/120 (33%) returned completed questionnaires, 25/40 (68.4%) reported the reason for appointment was test results. Travel time and school attendance were identified as main advantages. Mean parental rating score for the service was 8/10 with 21/40 (54%) scoring the service as 10/10.

CONCLUSION

The initial results of this audit are promising. Structured telephone appointments have a key role in delivering patient care in paediatric gastroenterology and have benefits to health professional, parent/carer and patients. These clinics have now been widely adopted by all members of our department.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Improving Access to Gastroenterologist Using eConsultation: A Way to Potentially Shorten Wait Times

Background

Wait times for gastroenterologists in Canada continue to exceed recommended targets. Electronic consultation (eConsult) may reduce the need for face-to-face gastroenterologist visits.

Objective

The goal of this study was to identify the cases submitted to gastroenterologists though the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service and explore their impact on primary care physicians' (PCPs) courses of action.

Methods

Gastroenterology cases submitted between June 2013 and January 2015 were categorized using a modification of the International Classification for Primary Care (ICPC-2) taxonomy. Question type (e.g., diagnosis or management) was classified using a validated taxonomy.

Results

Of the 121 gastroenterology consults reviewed, 33% were related to hepatology, 23% to GI symptoms, and 13% to specific luminal diseases. Among hepatology eConsults (n=40), 47% pertained to abnormal liver function testing. Overall, 51% of eConsults were related to diagnosis, 30% to management, 9% to drug treatments and 7% to procedures. PCPs received a reply within a median of 2.9 days. Only 25% of cases resulted in a face-to-face referral.

Conclusions

The eConsult service provided timely, highly regarded advice from gastroenterologists directly to PCPs and often eliminated the need for a face-to-face consultation. An evaluation of the most commonly-posed questions could inform future continuing medical education activities for PCPs.

E-health in inflammatory bowel diseases: More challenges than opportunities?

Patients with inflammatory bowel disease need close monitoring for an optimal disease management. For this, e-health technologies are promising tools. But the current evidence for the implementation of e-health in inflammatory bowel disease is weak. For this a critical evaluation of the existing evidence is presented. Furthermore some essential conditions need to be full-filled. We need a robust digital infrastructure that is workable for the patient and the healthcare provider. Important legal issues need to be solved to protect the patient. And the e-health technologies will have to proof their durability, feasibility and acceptance for the patient on the long term.