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Young VN, Ma Y, Rosen CA, Schneider SL. Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care. Otolaryngol Head Neck Surg 2024. [PMID: 38613195 DOI: 10.1002/ohn.779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. STUDY DESIGN Prospective cohort. SETTING Tertiary laryngology center. METHODS Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. RESULTS Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12). CONCLUSION Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.
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Affiliation(s)
- VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco Voice and Swallowing Center, San Francisco, California, USA
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco Voice and Swallowing Center, San Francisco, California, USA
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco Voice and Swallowing Center, San Francisco, California, USA
| | - Sarah L Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco Voice and Swallowing Center, San Francisco, California, USA
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Fujiki RB, Sanders PW, Anthony BP, Parker NP, Sivasankar MP, Halum S. Can Resident Auditory-Perceptual Voice Assessments Predict Medical Urgency of Voice Disorders? J Voice 2024; 38:181-188. [PMID: 34479778 DOI: 10.1016/j.jvoice.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND/OBJECTIVES Growing reliance on telemedicine has created new triaging challenges. This study investigated how effectively otolaryngology resident auditory-perceptual voice assessments performed via telemedicine determined the need for urgent in-person clinic visits. METHODS Twelve otolaryngology resident physicians (PGY1-PGY5) performed auditory-perceptual assessments on 25 voice samples recorded during initial voice evaluations. Voice samples were balanced in severity and taken in equal numbers from patients with the following diagnoses: benign laryngeal lesions, laryngeal cancer, functional voice disorders, laryngeal edema (associated with LPR), and laryngeal paralysis/paresis. Urgent diagnoses were defined as laryngeal cancer and severe unilateral laryngeal paralysis. For each voice sample, residents were initially blinded to patient medical history. Residents rated severity of voice disorder, predicted patient diagnosis, and determined the urgency of seeing the patient in clinic. Residents then reviewed information from the patient's medical history and again rated urgency of voice disorder. RESULTS On average, residents identified urgent voice disorders in 56% of cases. After reviewing medical history, this number significantly increased to 77% (P = 0.001). Voice severity, smoking history, time since onset, and course of symptoms were considered most influential when determining medical urgency of voice patients. Year in residency program had no effect on rating accuracy. As expected, diagnostic accuracy of auditory-perceptual assessments was low, ranging from 40% for laryngeal paralysis/paresis to 5% for laryngeal edema. CONCLUSION Auditory-perceptual voice assessment, combined with medical history, predicted most medically urgent voice disorders. Further work should investigate if task-specific training might improve these results and which medical history items are most critical. Until accuracy of auditory-perceptual assessment of medical urgency is improved, these data underscore the importance of laryngeal examination in identifying medical urgency and etiology of dysphonia.
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Affiliation(s)
| | | | - Benjamin P Anthony
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine
| | - Noah P Parker
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine
| | | | - Stacey Halum
- Department of Speech, Language, and Hearing Sciences, Purdue University; Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine.
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Krekelberg MO, Ruckart JD, Morton-Jones ME, Lacy AL, Madden LL, Ruckart KW. Evaluating Geographic Access to Interdisciplinary Laryngology and Speech-Language Pathology Clinic Models in the Southeast Region of the United States. J Voice 2023:S0892-1997(23)00327-2. [PMID: 37932131 DOI: 10.1016/j.jvoice.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE An interdisciplinary model of care for the evaluation and treatment of voice, swallowing, and upper airway disorders with laryngologists and specialized speech-language pathologists is known to increase revenue, attendance to visits, patient adherence, and most importantly, improve patient outcomes. Individuals who live outside of areas with high population density often have reduced geographic access to this specialized care. The primary aim of this study is to identify the percentage of the population that has an "extended drive time" to access an interdisciplinary clinic in the Southeast region of the United States. STUDY DESIGN NA. METHODS Interdisciplinary laryngology and speech-language pathology clinics were identified via publicly accessible information including an internet search and state department of public health databases. Included clinics had at least one full-time fellowship-trained laryngologist and at least one full-time speech-language pathologist on staff. Descriptive statistics and visual representation of the results were achieved with the use of Smappen, a location intelligence online platform, to identify the percent of the population with a drive time greater than 1 hour. RESULTS 47.24% of the Southeast population of the United States must drive over 1 hour to access an interdisciplinary clinic. Visual representations of these data are included and generated by Smappen. CONCLUSIONS While close geographic proximity does not ensure access to care, it can increase the likelihood that healthcare services will be used. This study identified the population in the Southeast region of the United States with extended drive time to interdisciplinary voice and swallowing centers due to their geographic distance from these centers. The results from this study support the need for increased geographic access to specialty care clinics, specifically voice, swallowing, and upper airway care, and provide insight into potential sites for interdisciplinary centers based on population density in areas that are underserved.
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Affiliation(s)
- Maris O Krekelberg
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - James D Ruckart
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Mariah E Morton-Jones
- Department of Otolaryngology, School of Kinesiology, Auburn University, Auburn, Alabama
| | - Alexa L Lacy
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kathryn W Ruckart
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Batista DDJ, da Silva RD, Martins AA, de Araújo CM, Santos RS, Filho OG, Taveira KVM, Ribeiro VV. Internal Consistency of the Voice Handicap Index in Individuals With Dysphonia: A Systematic Review and Meta-Analysis. J Voice 2023:S0892-1997(23)00253-9. [PMID: 37778959 DOI: 10.1016/j.jvoice.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To analyze the internal consistency of the Voice Handicap Index (VHI) for evaluating the vocal handicap of individuals with dysphonia. METHODS This is a systematic review. Studies with a cross-sectional design and including a population of individuals with dysphonia, which validated the VHI and analyzed its internal consistency, were included. The following electronic databases were searched: Cochrane Library, EMBASE, LILACS, and PubMed, including Medline, Scopus, and Web of Science. A manual search was performed in gray literature through the Biblioteca Digital Brasileira de Teses e Dissertações and ProQuest Dissertation & Theses. In addition, the list of references of studies selected in the electronic search was mapped, and an expert in the area was consulted. Two reviewers blindly and independently conducted the selection, data extraction, and analysis of the risk of bias, the certainty of the evidence, and good psychometric measures. A meta-analysis was performed with a random effects model using the JAMOVI 2.3.2 software. RESULTS Forty-nine studies were analyzed. In risk of bias assessment, the studies were classified as having inadequate structural validity and very good internal consistency. The analysis of good psychometric properties indicated indeterminate structural validity and insufficient internal consistency. The overall value of Cronbach's alpha was estimated at 0.94, thus suggesting a very good internal consistency. However, there was high heterogeneity. The level of certainty of the evidence was too low for internal consistency. CONCLUSION The VHI proved to be a consistent and reliable patient-reported outcome measure to evaluate voice handicap in individuals with dysphonia; however, studies are heterogeneous, and the certainty of evidence is very low.
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Affiliation(s)
- Denis de Jesus Batista
- Decision Models and Health, Statistics Department, Universidade Federal da Paraíba, João Pessoa, Paraíba, Brazil; Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Associated Graduate Program in Speech and Language Therapy, Universidade Federal da Paraíba, Universidade Federal do Rio Grande do Norte and Universidade Estadual de Ciências da Saúde de Alagoas, Curitiba, Paraná, Brazil.
| | - Rayane Délcia da Silva
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Communication Disorders, Universidade Tuiuti do Paraná, Curitiba, Paraná, Brazil.
| | - Agnes Andrade Martins
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Dentistry, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
| | - Cristiano Miranda de Araújo
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Communication Disorders, Universidade Tuiuti do Paraná, Curitiba, Paraná, Brazil; Dentistry, Universidade Tuiuti do Paraná, Curitiba, Paraná, Brazil.
| | - Rosane Sampaio Santos
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Graduate Program in Communication Disorders, Universidade Tuiuti do Paraná.
| | - Odilon Guariza Filho
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil.
| | - Karinna Veríssimo Meira Taveira
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Associated Graduate Program in Speech and Language Therapy, Universidade Federal da Paraíba, Universidade Federal do Rio Grande do Norte and Universidade Estadual de Ciências da Saúde de Alagoas, Curitiba, Paraná, Brazil; Universidade Federal do Rio Grande do Norte, Curitiba, Paraná, Brazil.
| | - Vanessa Veis Ribeiro
- Núcleo de estudos Avançados em Revisões Sistemáticas e Meta-análise (NARSM), Rua Padre Ladislau Kula, 395 - Santo Inácio, Curitiba, PR 82010-210, Brazil; Associated Graduate Program in Speech and Language Therapy, Universidade Federal da Paraíba, Universidade Federal do Rio Grande do Norte and Universidade Estadual de Ciências da Saúde de Alagoas, Curitiba, Paraná, Brazil; Speech and Language Therapy Course and the Graduate Program in Medical Sciences, Universidade de Brasília, Universidade Federal do Rio Grande do Norte and Universidade Estadual de Ciências da Saúde de Alagoas, Brasília, Distrito Federal, Brazil.
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De Taeye R, Van Lierde K, Alighieri C. Telepractice in the diagnosis and treatment of pediatric speech-language disorders: The opinions and experiences of speech-language pathologists. Int J Pediatr Otorhinolaryngol 2023; 169:111560. [PMID: 37116275 DOI: 10.1016/j.ijporl.2023.111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE This prospective cross-sectional study aimed to investigate the opinions and experiences with telepractice (TP) of Dutch-speaking speech-language pathologists (SLPs) living in the Dutch-speaking part of Belgium (Flanders). This study will help to optimize care for children with speech-language disorders as we will gain more insight into the experienced barriers and facilitators while using TP for assessing and treating these disorders. METHOD Twenty-nine Dutch-speaking speech-language pathologists living in Flanders (age category 20-30 years: n = 16/29, 55.2%, 31-40 years: n = 10/29, 34.2%, 41-50 years: n = 2/29, 6.9%, 51-60 years: n = 1/29, 3.4%) were recruited through the social media. An online questionnaire was developed based on the available literature and administered to the SLPs. To compare the opinions and experiences of SLPs with TP, χ2 tests or Fisher's exact tests were used. RESULTS The study showed a statistically significant association between years of clinical experience of SLPs and their opinion that TP does not provide more options in a clinical setting compared to face-to-face contact. SLPs who had expertise in multiple domains experienced significantly more added value of TP during the corona pandemic than SLPs who had expertise in only one specific domain. Additionally, SLPs who worked in a private practice indicated significantly more difficulties in developing a therapeutic relationship due to a lack of personal contact than SLPs who worked in other settings. 51.7% (15/29) of the SLPs experienced technical barriers using TP. CONCLUSION Expertise in multiple domains of pediatric speech-language therapy resulted in experiencing more added value of TP during the corona pandemic, possibly because of the experience of multiple different and simultaneous advantages of TP in several domains. Additionally, SLPs in a private practice experienced more difficulties in developing a therapeutic relationship due to a lack of personal contact with their clients. This is in contrast to hospitals where children are often seen for a shorter period. Hence, there may be less chance of a negative perception of relationships with clients. Another conclusion is that treatment drop-out was not larger using TP compared to face-to-face therapy. However, SLPs experienced that the use of TP was not promoted/encouraged by their employer possibly because of technical barriers. It is hoped that the findings of this study will help SLPs and policymakers overthrow existing barriers and make telepractice a substantial, effective, and efficient service delivery model.
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Affiliation(s)
- Robin De Taeye
- Department of Rehabilitation Sciences, Centre for Speech and Language Sciences (CESLAS), Ghent University, Corneel Heymanslaan 10, 2P1, 9000, Gent, Belgium
| | - Kristiane Van Lierde
- Department of Rehabilitation Sciences, Centre for Speech and Language Sciences (CESLAS), Ghent University, Corneel Heymanslaan 10, 2P1, 9000, Gent, Belgium
| | - Cassandra Alighieri
- Department of Rehabilitation Sciences, Centre for Speech and Language Sciences (CESLAS), Ghent University, Corneel Heymanslaan 10, 2P1, 9000, Gent, Belgium.
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Smith JD, McConville K, Tiner MK, Baldner EF, Rosenberg M, Kupfer RA, Hogikyan ND, Morrison RJ. Examining Use and Effectiveness of Teletherapy for Patients with Dysphonia. J Voice 2023:S0892-1997(23)00034-6. [PMID: 36863957 DOI: 10.1016/j.jvoice.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE(S)/HYPOTHESIS Virtual therapy (teletherapy) for patients with dysphonia has become ubiquitous in the COVID-19 era. However, barriers to widespread implementation are evident, including unpredictable insurance coverage attributed to limited evidence supporting this approach. In our single-institution cohort, our objective was to show strong evidence for use and effectiveness of teletherapy for patients with dysphonia. STUDY DESIGN Single institution, retrospective cohort study. MATERIAL AND METHODS This was an analysis of all patients referred for speech therapy with dysphonia as primary diagnosis from 4/1/2020 to 7/1/2021 and in whom all therapy sessions were delivered in a teletherapy format. We collated and analyzed demographics and clinical characteristics and adherence to the teletherapy program. We assessed changes in perceptual assessments and vocal capabilities (GRBAS, MPT), patient-reported outcomes (V-RQOL), and metrics of session outcomes (complexity of vocal tasks, carry-over of target voice) pre- and post-teletherapy using student's t test and chi-square test. RESULTS Our cohort included 234 patients (mean [SD] age 52 [20] years) residing a mean (SD) distance of 51.3 (67.1) miles from our institution. The most common referral diagnosis was muscle tension dysphonia (n = 145, 62.0% patients). Patients attended a mean (SD) of 4.2 (3.0) sessions; 68.0% (n = 159) of patients completed four or more sessions and/or were deemed appropriate for discharge from teletherapy program. Statistically significant improvements were seen in complexity and consistency of vocal tasks with consistent gains in carry-over of target voice for isolated tasks and connected speech. CONCLUSIONS Teletherapy is a versatile and effective approach for treatment of patients with dysphonia of varying age, geography, and diagnoses.
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Affiliation(s)
- Joshua D Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA
| | - Katherine McConville
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA; Department of Speech-Language Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Margaret K Tiner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA; Department of Speech-Language Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Ford Baldner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA; Department of Speech-Language Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Marci Rosenberg
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA; Department of Speech-Language Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA
| | - Robert J Morrison
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Vocal Health Center, Ann Arbor, Michigan, USA.
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Kim ME, Sund LT, Morton M, Kim J, Choi JS, Castro ME. Provider and Patient Satisfaction with Telemedicine Voice Therapy During the COVID-19 Pandemic. J Voice 2022:S0892-1997(22)00211-9. [PMID: 36038478 PMCID: PMC9289043 DOI: 10.1016/j.jvoice.2022.07.009] [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: 05/01/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The COVID-19 pandemic expanded the use of telemedicine, but there is no literature exploring both patient and provider satisfaction specifically in the provision of voice therapy. This study aims to investigate patient and provider satisfaction with virtual voice therapy, its associated factors, and any correlation between the two. METHODS Cross-sectional study. Participants included 226 adults who underwent voice therapy delivered via telepractice at the USC Voice Center between April and October 2020. Patients and providers self-reported their level of satisfaction on a visual analog scale (VAS; range 0-100). Patient satisfaction was additionally measured using a previously validated Telemedicine Satisfaction Questionnaire (TSQ; range 1-5), and a binary question about their desire to choose telemedicine over in-person therapy in the future. Three speech-language pathologists rated provider satisfaction for all 226 patients. Patient satisfaction survey was completed by 55 patients. Multivariable linear regression analyses and linear mixed-effects models were used to assess the results. RESULTS Patient and provider mean (SD) VAS satisfaction scores were 86.8 (18.6) and 80.6 (19.7), respectively. The mean (SD) TSQ score was 4.4 (0.6). In a multivariable model, patient satisfaction levels were significantly higher for hypofunctional than for hyperfunctional dysphonia diagnoses. Forty-four (73%) patients reported they would prefer telemedicine voice therapy over in-person appointments, which was significantly correlated with internet reliability (P = 0.04). For providers, satisfaction was significantly lower for patients whose diagnosis had changed after initiation of voice therapy (Δ = -16.0 [95% CI: -28.7 to -3.2]) and for encounters with Asian patients compared to White patients (Δ = -11.6 [95% CI: -18.9 to -4.2]). Patient and provider satisfaction scores were weakly correlated (r = 0.19). CONCLUSIONS Our findings suggest that virtual voice therapy is not simply an alternative to in-person service, but rather an effective method useful beyond the current pandemic with proper diagnosis and technical support.
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Affiliation(s)
- Mary E Kim
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of USC, University of Southern California Caruso, Los Angeles, California.
| | - Lauren Timmons Sund
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of USC, University of Southern California Caruso, Los Angeles, California
| | - Mariah Morton
- Auburn University School of Kinesiology, Auburn, Albama
| | - James Kim
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of USC, University of Southern California Caruso, Los Angeles, California
| | - Janet S Choi
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota
| | - M Eugenia Castro
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of USC, University of Southern California Caruso, Los Angeles, California
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Sresuganthi JR, Nallamuthu A, Boominathan P. Comparison of Client-Led Asynchronous and Clinician-Led Synchronous Online Methods for Evaluation of Subjective Vocal Measures in Teachers: A Feasibility Study. J Voice 2022:S0892-1997(22)00127-8. [PMID: 35641382 DOI: 10.1016/j.jvoice.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND COVID-19 has transformed face to face teaching in classrooms to online and hybrid modes. Increased vocal intensity/ pitch to call attention of students and transact in the online class, inappropriate posture (head, neck & upper trunk) while using the laptop and other online tools cause vocal loading leading to voice related concerns in teachers. Tele voice assessment is a feasible alternative means to seek professional help in the current situation and possibly in the future too. Client-led asynchronous and clinician-led synchronous voice recordings for clinical vocal measures among school teachers were compared in this study. METHOD Twenty-five school teachers (21 females & four males) from Chennai consented to the study. Information of voice use, its impact on the day-to-day situations, self-perception of vocal fatigue, and their recorded voice sample (phonation & speaking) were obtained online (asynchronous mode). Within a period of ten days, the clinician-led synchronous session was planned on a mutually convenient time for obtaining voice samples through zoom call. The voice samples obtained were compared for clinical measures and perceptual voice evaluation. RESULTS Participants reported of vocal symptoms and increased vocal fatigue scores. The maximum phonation time values obtained through synchronous mode were lesser when compared to asynchronous mode. Also, variability was noted in the perceptual vocal measures of voice samples obtained through synchronous mode. During synchronous voice recording & evaluation, the background noise, internet stability, audio enhancement feature, and microphone placement & quality could be monitored, and immediate feedback was provided. Additionally, the asynchronous recording can be supplemented for synchronous recording, with clear instructions & demonstration. CONCLUSION This study explored the feasibility of using synchronous and asynchronous voice recording for voice analysis in school teachers. The findings could serve as a base to understand the advantages and challenges of using client-led asynchronous and clinician-led synchronous methods for estimating vocal measures.
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Affiliation(s)
| | - Aishwarya Nallamuthu
- Department of Speech Language & Hearing Sciences, Sri Ramachandra Institute of Higher Education & Research, Chennai, Tamil Nadu, India.
| | - Prakash Boominathan
- Department of Speech Language & Hearing Sciences, Sri Ramachandra Institute of Higher Education & Research, Chennai, Tamil Nadu, India
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Reverberi C, Gottardo G, Battel I, Castagnetti E. The neurogenic dysphagia management via telemedicine: a systematic review. Eur J Phys Rehabil Med 2022; 58:179-189. [PMID: 34605620 PMCID: PMC9980496 DOI: 10.23736/s1973-9087.21.06921-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Telerehabilitation is the provision of rehabilitation remotely through Information and Communication Technologies (ICT). Recently, there has been an increase of interest in its application thanks to increasing a new technology. The aim of this systematic review was to examine the evidence of the literature regarding the management of neurogenic dysphagia via telerehabilitation, compared to face-to-face rehabilitation treatment. The secondary aim was to create recommendations on telerehabilitation sessions for patients diagnosed with neurogenic dysphagia. EVIDENCE ACQUISITION The databases were: Medline, Embase, CINAHL, Scopus. A total of 235 records emerged from bibliographic research, manual search of full text and from gray literature, published until January 2021. Two blinded authors carried out titles and abstract screening and followed by full-text analysis. Sixteen articles were included in the systematic review and assessed through critical appraisal tools. EVIDENCE SYNTHESIS The research shows that the majority of the studies on neurogenic dysphagia involved the Clinical Swallow Examination via telerehabilitation, compared with the in-person modality. Significant levels of agreement and high satisfaction from clinicians and patients are reported to support the use of telerehabilitation. Based on the results of this systematic review and qualitative analysis, the authors developed practical recommendations for the management of telerehabilitation sessions for patients with neurogenic dysphagia. CONCLUSIONS Despite the presence of barriers, telerehabilitation allowed healthcare provision and increasing access to care and services with specialized professionals, remote rehabilitation can be a valid resource during the health emergency due to COVID-19.
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Affiliation(s)
- Cristina Reverberi
- Department of Health Professions, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | | | - Irene Battel
- Department of Physical and Medical Rehabilitation, San Giovanni e Paolo Civil Hospital, Azienda ULSS3 Serenissima, Venice, Italy -
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Payten CL, Nguyen DD, Novakovic D, O'Neill J, Chacon AM, Weir KA, Madill CJ. Telehealth voice assessment by speech language pathologists during a global pandemic using principles of a primary contact model: an observational cohort study protocol. BMJ Open 2022; 12:e052518. [PMID: 35039289 PMCID: PMC8764716 DOI: 10.1136/bmjopen-2021-052518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION SARS-CoV-2, a highly contagious severe acute respiratory syndrome, has spread to most countries in the world and resulted in a change to practice patterns for the assessment and diagnosis of people with voice disorders. Many services are transitioning to telehealth models to maintain physical distancing measures and conserve personal protective equipment used by healthcare workers during laryngoscopy examinations. The speech-language pathology primary contact (SLPPC) assessment for patients referred to ear, nose and throat (ENT) services in Australia has been shown to reduce waiting times for assessment while streamlining access to ENT assessment and allied health practitioner treatment pathways. METHODS AND ANALYSIS A prospective observational cohort study will see patients in a newly developed telehealth model which uses the principles from a usual care SLPPC assessment protocol. Participants will be offered an initial telehealth assessment (speech-language pathology primary contact telehealth (SLPPC-T)) prior to being prioritised for a face-to-face laryngoscopy assessment to complete the diagnostic process. The telehealth assessment will collect sociodemographic information, personal and family medical history, key symptoms, onset and variability of symptoms, red-flag signs or symptoms for laryngeal malignancy, and clinical voice assessment data for auditory-perceptual and acoustic analysis. The study outcomes include (1) association of signs, symptoms and specific voice measures collected during SLPPC-T with voice disorder classification provided after laryngoscopy; (2) degree of concordance between voice disorder classification after SLPPC-T and after laryngoscopy; (3) health service and patient-related costs and health outcomes of the SLPPC-T; (4) patient and stakeholder views and beliefs about the SLPPC-T process. ETHICS AND DISSEMINATION Ethical approval has been granted prior to commencement of the study enrolment by the Gold Coast Hospital and Health Service Human Research Ethics Committee (reference number HREC/2020/QGC/62832). Results will be shared through the publication of articles in peer-reviewed medical journals and presentation at national and international scientific meetings. TRIAL REGISTRATION NUMBER ACTRN12621000427875.
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Affiliation(s)
- Christopher L Payten
- Department of Speech Pathology, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Duy Duong Nguyen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Novakovic
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - John O'Neill
- Department of Ear, Nose and Throat, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Antonia M Chacon
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kelly A Weir
- School of Allied Health Sciences, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
- Department of Research and Education, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Catherine J Madill
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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11
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Almubark BM, Majrashi N, Alghusun N, Alhammad M, Alhthifi F, Alyahya RSW. Telehealth Clinical Practice Guide for Occupational Therapy, Physical Therapy, and Speech and Language Pathology: A Saudi and Middle Eastern Guide. Telemed J E Health 2021; 28:636-642. [PMID: 34529497 DOI: 10.1089/tmj.2021.0021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Telehealth refers to the application of telecommunications technology to deliver clinical services at a distance by linking clinician to patient, caregiver, or any person(s) involved in client care for assessment, intervention, consultation, and supervision. Telehealth for occupational therapy (OT), physical therapy (PT), and speech and language pathology (SLP) have produced service delivery venues that are of great benefit during the coronavirus disease 2019 pandemic. The concept of telehealth for rehabilitation services is relatively new in the Middle East, and no specialty-specific clinical practice standards or guidelines are published to guide the rehabilitation practitioners. Therefore, a specialty-specific telehealth practice guide for rehabilitation practitioners has been developed by an expert panel in the field of rehabilitation. This guide is documented in this article. Such a guide will be beneficial when providing tele-evaluation, teleintervention/telerehabilitation, teleconsultation, and telemonitoring through communication technologies. The purpose of this guide is to enable understanding of core telehealth clinical principles and aid the provision of OT, PT, and SLP telehealth services in Saudi Arabia. Also, the guide can potentially be implemented in other Middle Eastern countries. The guide is based on key telehealth guidelines involving the American Occupational Therapy Association telehealth resources, American Physical Therapy Association, American Speech and Hearing Association, telemedicine policies in Saudi Arabia by the national health information center at the Saudi Health Council, and a blueprint for telerehabilitation guidelines that are based on the American Telemedicine Association's Core Standards for Telemedicine Operations.
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Affiliation(s)
- Bazah M Almubark
- Occupational Therapy Unit, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Norah Alghusun
- Department of Communication and Swallowing Disorders, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Faisal Alhthifi
- Rehabilitation Services, Al Qassim University, Qassim, Saudi Arabia
| | - Reem S W Alyahya
- Department of Communication and Swallowing Disorders, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, Alfaisal University, Saudi Arabia
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12
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Weerathunge HR, Segina RK, Tracy L, Stepp CE. Accuracy of Acoustic Measures of Voice via Telepractice Videoconferencing Platforms. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2021; 64:2586-2599. [PMID: 34157251 PMCID: PMC8632479 DOI: 10.1044/2021_jslhr-20-00625] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/19/2020] [Accepted: 03/23/2021] [Indexed: 05/31/2023]
Abstract
Purpose Telepractice improves patient access to clinical care for voice disorders. Acoustic assessment has the potential to provide critical, objective information during telepractice, yet its validity via telepractice is currently unknown. The current study investigated the accuracy of acoustic measures of voice in a variety of telepractice platforms. Method Twenty-nine voice samples from individuals with dysphonia were transmitted over six video conferencing platforms (Zoom with and without enhancements, Cisco WebEx, Microsoft Teams, Doxy.me, and VSee Messenger). Standard time-, spectral-, and cepstral-based acoustic measures were calculated. The effect of transmission condition on each acoustic measure was assessed using repeated-measures analyses of variance. For those acoustic measures for which transmission condition was a significant factor, linear regression analysis was performed on the difference between the original recording and each telepractice platform, with the overall severity of dysphonia, Internet speed, and ambient noise from the transmitter as predictors. Results Transmission condition was a statistically significant factor for all acoustic measures except for mean fundamental frequency (f o). Ambient noise from the transmitter was a significant predictor of differences between platforms and the original recordings for all acoustic measures except f o measures. All telepractice platforms affected acoustic measures in a statistically significantly manner, although the effects of platforms varied by measure. Conclusions Overall, measures of f o were the least impacted by telepractice transmission. Microsoft Teams had the least and Zoom (with enhancements) had the most pronounced effects on acoustic measures. These results provide valuable insight into the relative validity of acoustic measures of voice when collected via telepractice. Supplemental Material https://doi.org/10.23641/asha.14794812.
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Affiliation(s)
- Hasini R. Weerathunge
- Department of Biomedical Engineering, Boston University, MA
- Department of Speech, Language and Hearing Sciences, Boston University, MA
| | - Roxanne K. Segina
- Department of Speech, Language and Hearing Sciences, Boston University, MA
| | - Lauren Tracy
- Department of Otolaryngology—Head & Neck Surgery, Boston University School of Medicine, MA
| | - Cara E. Stepp
- Department of Biomedical Engineering, Boston University, MA
- Department of Speech, Language and Hearing Sciences, Boston University, MA
- Department of Otolaryngology—Head & Neck Surgery, Boston University School of Medicine, MA
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13
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Wang JC, Elson NC, Epperson MV, Doarn CR, Altaye M, Tabangin ME, Patil RD, Patil YJ. A Report on the Use of Telehealth in Otolaryngology: In the Pre COVID-19 Era. Telemed J E Health 2021; 28:334-343. [PMID: 34028286 DOI: 10.1089/tmj.2021.0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the integration of and barriers to the utilization of telehealth technology and its components (telemedicine, e-Health, m-health) in daily otolaryngologic practice before the SARS CoV-2 (COVID-19) pandemic. Methods: This cross-sectional study was conducted at a tertiary academic center. A national survey of members of the American Academy of Otolaryngology-Head and Neck Surgery was administered. Descriptive analyses were performed to determine how telehealth was employed in otolaryngologists' practices. Results: A total of 184 surveys were completed. Telehealth technology was used by 50% of otolaryngologists surveyed. Regions with the largest percentage of physicians using telehealth were the Mid-Atlantic region (84%) and West Coast (67%). Most otolaryngologists indicated that they were familiar with telehealth or any of its components and how it is used in practice (52-83%), they had heard of telehealth or any of its components but were unsure what the terms specifically entailed (17-42%); 53% were satisfied with their current use of telehealth and electronic medical record (EMR); and 72% were comfortable utilizing smart devices for patient care. Most otolaryngologists (65%) indicated reimbursement as the biggest limitation to implementing telehealth, and 67% believed that typing was a hindrance to EMR utility. Conclusion: Half of the surveyed otolaryngologists used some form of telehealth at the time of the survey. The most commonly cited obstacle to physician adoption of telehealth was reimbursement. Although the adoption of telehealth technology was still limited in the field of otolaryngology based on this study, we are now seeing significant change due to the COVID-19 pandemic.
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Affiliation(s)
- James C Wang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Nora C Elson
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Madison V Epperson
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Charles R Doarn
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Meredith E Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Reena Dhanda Patil
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
| | - Yash J Patil
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,This manuscript was presented at the Triological Society Combined Sections Meeting January 23-25, 2020
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14
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Hoi KK, Curtis SH, Driver L, Wisnosky E, Zopf DA, Bohm LA. Adoption of Telemedicine for Multidisciplinary Care in Pediatric Otolaryngology. Ann Otol Rhinol Laryngol 2021; 130:1105-1111. [PMID: 33629600 DOI: 10.1177/0003489421997651] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The COVID-19 pandemic has introduced a period of social isolation that has challenged the ability of providers to uphold in-person patient care. Although commonplace in pediatric otolaryngology, multidisciplinary clinics pose a unique challenge during this time due to increased infection risk from multiple patient-provider interactions. Guidance on the application of telemedicine for multidisciplinary clinics in pediatric otolaryngology is limited. METHODS We provide comprehensive guidance on best practices for conducting telemedicine visits for a number of multidisciplinary otolaryngology clinics using our experiences at a single tertiary care children's hospital. A review of literature to support the adoption of telemedicine in multidisciplinary pediatric otolaryngology is also incorporated. RESULTS Telemedicine was successfully adopted for 7 multidisciplinary pediatric clinics with a variety of specialists: aerodigestive disorders, congenital hearing loss, microtia/aural atresia, orofacial clefting, sleep disorders, tracheostomy care, and velopharyngeal dysfunction. CONCLUSIONS Telemedicine is feasible for a variety of multidisciplinary clinics and its optimization is critical for providing care to complex pediatric otolaryngology patients during the COVID-19 pandemic and beyond.
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Affiliation(s)
- Karen K Hoi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stuart H Curtis
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Lynn Driver
- Department of Speech-Language Pathology, Michigan Medicine, Ann Arbor, MI, USA
| | - Erica Wisnosky
- Department of Speech-Language Pathology, Michigan Medicine, Ann Arbor, MI, USA
| | - David A Zopf
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA.,Department of Biomedical Engineering, Michigan Engineering, Ann Arbor, MI, USA
| | - Lauren A Bohm
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
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15
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Becker DR, Gillespie AI. In the Zoom Where It Happened: Telepractice and the Voice Clinic in 2020. Semin Speech Lang 2021; 42:64-72. [PMID: 33596605 DOI: 10.1055/s-0040-1722750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Telemedicine-conveying medical information virtually for planning, diagnosis, or treatment-has been a part of the American medical system for over 100 years. A constantly evolving modality, telepractice was a supplemental care delivery system for most speech-language pathologists (SLPs) until March 2020 when the COVID-19 pandemic forced clinical operations to halt in-person activities and convert as much as possible to virtual platforms. The purpose of this article is to provide an overview of the need for telepractice prior to and beyond the current pandemic, the efficacy of telepractice for the voice-specialized SLP, limitations of telepractice, and best practices for providing care over telepractice with a specific focus on voice disorder diagnosis and treatment.
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Affiliation(s)
- Diana Rose Becker
- Emory Voice Center, Department of Otolaryngology, Emory Healthcare, Emory University Hospital Midtown, Atlanta, Georgia
| | - Amanda I Gillespie
- Emory Voice Center, Department of Otolaryngology, Emory Healthcare, Emory University Hospital Midtown, Atlanta, Georgia
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16
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Doll EJ, Braden MN, Thibeault SL. COVID-19 and Speech-Language Pathology Clinical Practice of Voice and Upper Airway Disorders. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:63-74. [PMID: 33332145 PMCID: PMC8740584 DOI: 10.1044/2020_ajslp-20-00228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/20/2020] [Accepted: 10/14/2020] [Indexed: 05/31/2023]
Abstract
Purpose Evaluation and management of voice and upper airway disorders in adults and children, by speech-language pathologists worldwide, have been significantly altered by the COVID-19 pandemic. Secondary to the pathogenic nature of the virus in the respiratory tract and upper airway, it is essential that speech-language pathologists who specialize in these disorders are knowledgeable of current practices to provide evidence-based care while minimizing viral transmission. Understanding how and when SARS-CoV-2 spreads is critical to the development of effective infection prevention within clinical practices. Method We established an evidence-based clinical practice guide for clinicians working with voice and upper airway through a comprehensive evaluation of peer-reviewed journals, non-peer-reviewed manuscripts on preprint servers, national health guidelines, and published and online consensus statements and emerging data. Emphasis was placed on risk mitigation for viral transmission via safe clinical practices, including evaluative procedures, therapy including telehealth, personal protective equipment, room, staffing, and distancing considerations. Results/Conclusions While knowledge relevant to viral transmission of SARS-CoV-2 is rapidly evolving, there is a paucity of literature specific to the evaluation and treatment of voice and upper airway disorders. Within these confines and given the potentially significant high risk of infection secondary to the nature of COVID-19, we summarize current considerations and recommend best practices that maximize risk mitigation whereby ensuring patient and provider safety.
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17
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Tracy LF, Segina RK, Cadiz MD, Stepp CE. The Impact of Communication Modality on Voice Production. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:2913-2920. [PMID: 32762517 PMCID: PMC7890225 DOI: 10.1044/2020_jslhr-20-00161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/04/2020] [Accepted: 06/18/2020] [Indexed: 06/11/2023]
Abstract
Purpose Communicating remotely using audio and audiovisual technology is ubiquitous in modern work and social environments. Remote communication is increasing in medicine and in voice therapy delivery, and this evolution may have an impact on speakers' voices. This study sought to determine whether these communication modalities impact the voice production of typical speakers. Method The speech acoustics of 12 participants with healthy voices were recorded as they held standardized conversations with a single investigator using three communication modalities: in-person, remote-audio, and remote-audiovisual. Participants rated their vocal effort on a 100-mm visual analog scale. Results Compared to in-person communication, self-ratings of vocal effort were statistically significantly increased for remote-audiovisual communication; vocal effort during remote-audio and in-person communication were not significantly different. In comparison to in-person communication, vocal intensity and smoothed cepstral peak prominence (CPPS) were statistically significantly higher during remote-audio and remote-audiovisual communication. Effect sizes for CPPS changes were larger than for sound pressure level (SPL), and changes in CPPS and SPL between in-person and remote-audiovisual communication were not significantly correlated. Conclusions Vocal effort and SPL were increased when using remote-audio and remote-audiovisual communication in comparison to in-person communication. Voice quality was also impacted by technology use, with changes in CPPS that were consistent with, but not fully explained by, increases in SPL. This may impact the telepractice delivery of voice therapy, and further investigation is warranted.
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Affiliation(s)
- Lauren F. Tracy
- Department of Otolaryngology—Head and Neck Surgery, Boston University School of Medicine, MA
| | - Roxanne K. Segina
- Department of Speech, Language and Hearing Sciences, Boston University, MA
| | - Manuel Diaz Cadiz
- Department of Speech, Language and Hearing Sciences, Boston University, MA
| | - Cara E. Stepp
- Department of Otolaryngology—Head and Neck Surgery, Boston University School of Medicine, MA
- Department of Speech, Language and Hearing Sciences, Boston University, MA
- Department of Biomedical Engineering, Boston University, MA
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18
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Krekeler BN, Vitale K, Yee J, Powell R, Rogus-Pulia N. Adherence to Dysphagia Treatment Recommendations: A Conceptual Model. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:1641-1657. [PMID: 32432958 PMCID: PMC7839030 DOI: 10.1044/2020_jslhr-19-00270] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 05/14/2023]
Abstract
Purpose Conceptual models of complex health problems are useful when designing targeted clinical interventions and focused research studies. Understanding and studying patient adherence often involves interplay among many factors that influence whether a patient successfully follows recommendations or completes a therapy program. Functional frameworks serve to arrange these factors visually, increasing interpretability and allowing for empirical testing of relationships among concepts. The purpose of this article is to integrate relevant factors from the literature into a comprehensive framework that describes adherence to dysphagia treatment. Method Using peer-reviewed, published guidelines regarding conceptual model construction, the authors created a list of potential factors that influence patient adherence to dysphagia-related treatment recommendations. During model construction, following extensive review of the literature and existing theories that have been applied in other areas of health care, factors were identified and grouped into conceptually similar domains (clusters). Clusters were arranged into larger categories that emerged during model optimization. Ultimately, two models were created: one that illustrates the interrelated factors of patient adherence and another that illustrates a subset of modifiable risk factors that a clinical speech-language pathologist may influence when developing a dysphagia treatment plan. Results Three general categories from 14 factors emerged based on relationships between factors and aspects of patient care: health factors, individual patient factors, and contextual factors. A second model consisting of modifiable risk factors included access, treatment type, patient perceptions, self-efficacy, health literacy, support factors, and provider bias. Conclusions This conceptual model allows clinicians and researchers to identify and explore the mechanisms driving adherence. Continual refinements of this model should be made as future studies uncover how the interconnectedness of factors affects adherence in dysphagia management. The models we have presented here are ready for clinical application and should also serve researchers as they generate hypotheses and design targeted research questions.
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Affiliation(s)
- Brittany N. Krekeler
- Department of Communication Sciences and Disorders, University of Wisconsin–Madison
- Otolaryngology–Head & Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Kailey Vitale
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI
| | - Joanne Yee
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI
| | - Ryan Powell
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI
| | - Nicole Rogus-Pulia
- Department of Communication Sciences and Disorders, University of Wisconsin–Madison
- Otolaryngology–Head & Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI
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19
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Zughni LA, Gillespie AI, Hatcher JL, Rubin AD, Giliberto JP. Telemedicine and the Interdisciplinary Clinic Model: During the COVID-19 Pandemic and Beyond. Otolaryngol Head Neck Surg 2020; 163:673-675. [PMID: 32484731 DOI: 10.1177/0194599820932167] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.
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Affiliation(s)
- Lisa A Zughni
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, USA
| | - Amanda I Gillespie
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Jeanne L Hatcher
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Adam D Rubin
- Lakeshore Ear, Nose, and Throat Center, St Clair Shores, Michigan, USA
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, USA
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20
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Nordio S, Innocenti T, Agostini M, Meneghello F, Battel I. The efficacy of telerehabilitation in dysphagic patients: a systematic review. ACTA ACUST UNITED AC 2019; 38:79-85. [PMID: 29967554 DOI: 10.14639/0392-100x-1816] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/17/2017] [Indexed: 11/23/2022]
Abstract
SUMMARY Telerehabilitation is the use of telecommunications technology for rehabilitation. Recently, some studies have shown positive effects of telerehabilitation of swallowing disorders, yet there are no systematic reviews verifying the evidence. The aim of this review is to assess the effects of telerehabilitation in the field of dysphagia as an alternative to face-to-face patient care, considering swallowing recovery and/or quality of life in different patient populations. We searched the Cochrane Library, MEDLINE, EMBASE, Google Scholar, Google Search and the grey literature from inception until December 2016 for publications written in English (keywords: telerehabilitation, telemedicine, dysphagia, swallowing disorders), which resulted in 330 records. Abstract screening and data extraction was carried out independently by two reviewers. Four papers were selected to read in full, and the methodological quality of the studies included was evaluated using Cochrane Collaboration's tool for assessing risk of bias. One study met our inclusion criteria (Wall et al. 2016), which showed that telerehabilitation improves adherence to treatment compared to patient-directed intervention. Although adherence is an important factor that influences the treatment outcome, clinical outcomes have to be examined in randomised controlled trials in order to reach evidence in this field. Lastly, this systematic review did not demonstrate the efficacy of telerehabilitation compared with face-to face therapy.
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Affiliation(s)
- S Nordio
- Fondazione Ospedale San Camillo IRCCS, Venice, Italy
| | - T Innocenti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Italy
| | - M Agostini
- Fondazione Ospedale San Camillo IRCCS, Venice, Italy
| | - F Meneghello
- Fondazione Ospedale San Camillo IRCCS, Venice, Italy
| | - I Battel
- Fondazione Ospedale San Camillo IRCCS, Venice, Italy
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Abstract
Purpose Telepractice offers prevention, assessment, treatment, and consultation at a distance. This article provides an overview of telepractice with specific considerations and examples related to voice across licensure requirements, state and federal laws, reimbursement, documentation, and telepractice methods. Conclusion As technology continues to advance and as client demand for telepractice services increases, practitioners need to create successful telepractice programs.
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Affiliation(s)
- Elizabeth U Grillo
- Department of Communication Sciences and Disorders, West Chester University, PA
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22
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Saadi R, Goldenberg D, Goldenberg D. Using Technology in Global Otolaryngology. Otolaryngol Clin North Am 2018; 51:555-561. [PMID: 29472013 DOI: 10.1016/j.otc.2018.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Technology is integral to the diverse diagnostics and interventions of Otolaryngology. Historically, major advances in this field derive from advances of associated technologies. Challenges of visualization and surgical access are increasingly overcome by integrating endoscopic, electronic, and robotic instruments. Otolaryngology is often limited to urban areas and large academic centers, making it difficult to allocate care and resources to many underserved populations. The widespread use of technology has important implications in regards to global access to this field as telemedicine is most effectively applied to specialties that are heavily reliant on data and visuals that may be electronically disseminated.
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Affiliation(s)
- Robert Saadi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, PO Box 850 H091, Hershey, PA 17033, USA
| | - Dana Goldenberg
- Tulane University, 6823 Street, Charles Avenue, New Orleans, LA 70118, USA
| | - David Goldenberg
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, PO Box 850 H091, Hershey, PA 17033, USA.
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Mayadevi M, Thankappan K, Limbachiya SV, Vidhyadharan S, Villegas B, Ouyoung M, Balasubramanian D, Menon JR, Sinha U, Iyer S. Interdisciplinary Telemedicine in the Management of Dysphagia in Head and Neck. Dysphagia 2018; 33:474-480. [PMID: 29404691 DOI: 10.1007/s00455-018-9876-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 01/23/2018] [Indexed: 11/29/2022]
Abstract
The study considered the feasibility and impact of interdisciplinary telemedicine discussions in the management of post-treatment dysphagia in patients with head and neck tumors. This is a retrospective analysis of patients with persistent dysphagia after treatment for head and neck pathology, at an institute in India. The cases were discussed in the telemedicine meeting conducted between host institute and a second unit in the United States. A monthly meeting was organized, using an internet-based video conference system. The ongoing swallowing problems and management were presented, and through discussions, a plan for further management was formulated and carried out. The Functional Oral Intake Scale (FOIS) was measured before and after the implementation of the plan. Twenty-six patients were discussed, out of which, 22 were head and neck malignancies. The recommendations concurred with that of the host unit in 18, differed for three and additive in five patients. The pre-treatment mean FOIS was 1.46 with a standard deviation of 0.989 and post-treatment mean improved to 3.92 with a standard deviation of 1.809 (p < 0.0001). The present study supports the success of an interdisciplinary telemedicine meeting to manage difficult cases of dysphagia in head and neck. The outcome in terms of the FOIS score improved significantly after implementing them. In addition to the direct patient benefits, the meeting helped to facilitate interdepartmental collaboration between two units treating similar sets of patients across the globe, in specialized clinical areas like dysphagia management.
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Affiliation(s)
- Mydhili Mayadevi
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India.
| | - Shashikant Vishnubhai Limbachiya
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
| | - Sivakumar Vidhyadharan
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
| | - Brenda Villegas
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of USC, University of Southern California, Los Angeles, USA
| | - Melody Ouyoung
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of USC, University of Southern California, Los Angeles, USA
| | - Deepak Balasubramanian
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
| | - Jayakumar R Menon
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
| | - Uttam Sinha
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of USC, University of Southern California, Los Angeles, USA
| | - Subramania Iyer
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita University, AIMS Ponekkara PO, Kochi, Kerala, India
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24
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Grillo EU. An Online Telepractice Model for the Prevention of Voice Disorders in Vocally Healthy Student Teachers Evaluated by a Smartphone Application. PERSPECTIVES OF THE ASHA SPECIAL INTEREST GROUPS 2017; 2:63-78. [PMID: 28890933 PMCID: PMC5590670 DOI: 10.1044/persp2.sig3.63] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This article describes the Global Voice Prevention Model (GVPM) facilitated with student teachers at West Chester University and the VoiceEvalU8 smartphone application (app) used to assess the effectiveness of the GVPM. Twenty-one participants completed 1 of 3 conditions (i.e., in-person GVPM, telepractice GVPM, and control). The in-person and telepractice conditions ran for 4 weeks during fall 2016, with 1 week dedicated to vocal education and vocal hygiene and 3 weeks spent in vocal training. The control condition ran for 1 week and included only vocal education and vocal hygiene. The VoiceEvalU8 app was used at pre- and post-condition twice a day for 5 days to record acoustic, perceptual, and aerodynamic voice measures. The study is ongoing; therefore, preliminary acoustic results for fundamental frequency (F0) and jitter% are presented from pre- to post-condition. During spring 2017, the participants were student teaching and using the VoiceEvalU8 app to record the voice measures before and after teaching all day. A new group of participants will be enrolled fall 2017 for selection into 1 of the 3 conditions and then continue on to student teaching spring 2018.
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Affiliation(s)
- Elizabeth U Grillo
- Department of Communication Sciences and Disorders, West Chester University, West Chester, PA
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25
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Wall LR, Ward EC, Cartmill B, Hill AJ, Porceddu SV. Examining user perceptions of SwallowIT: A pilot study of a new telepractice application for delivering intensive swallowing therapy to head and neck cancer patients. J Telemed Telecare 2016; 23:53-59. [DOI: 10.1177/1357633x15617887] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Consumer feedback and end-user perceptions provide important information regarding the clinical acceptability of new telepractice systems. This pilot investigation aimed to evaluate end-user perceptions of a new asynchronous telepractice application, ‘ SwallowIT’, designed to support patients to remotely complete intensive swallowing therapy during curative chemoradiotherapy (CRT) treatment for head and neck cancer (HNC). Insights were sought from 15 patients with oropharyngeal cancer who used SwallowIT to complete supported home swallowing therapy. Perceptions were evaluated via structured questionnaires, completed following initial orientation to SwallowIT and on completion of CRT. Semi-structured phone interviews were conducted ≥3 months post-treatment. The majority of patients reported positive initial perceptions towards SwallowIT for comfort (87%), confidence (87%), motivation (73%) and support (87%). No statistically significant change in perceptions was observed from baseline to end of CRT ( p > 0.05). Thematic analysis of interviews revealed four main themes: the ease of use of SwallowIT, motivating factors, circumstances which made therapy difficult, and personal preferences for service-delivery models. These preliminary findings demonstrate that SwallowIT was well-perceived by the current group of HNC consumers and suggest that SwallowIT may be well-accepted as an alternate service-delivery model for delivering intensive swallowing therapy during CRT.
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Affiliation(s)
- Laurelie R Wall
- Centre for Functioning and Health Research, Queensland Health, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Australia
- Centre for Research Excellence in Telehealth, The University of Queensland, Australia
| | - Elizabeth C Ward
- Centre for Functioning and Health Research, Queensland Health, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Australia
| | - Bena Cartmill
- Centre for Functioning and Health Research, Queensland Health, Australia
- Speech Pathology Department, Princess Alexandra Hospital, Queensland Health, Australia
| | - Anne J Hill
- School of Health and Rehabilitation Sciences, The University of Queensland, Australia
- Centre for Research Excellence in Telehealth, The University of Queensland, Australia
| | - Sandro V Porceddu
- Radiation Oncology Department, Princess Alexandra Hospital, Queensland Health, Australia
- School of Medicine, The University of Queensland, Australia
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26
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Isaki E, Farrell CF. Provision of Speech-Language Pathology Telepractice Services Using Apple iPads. Telemed J E Health 2015; 21:538-49. [DOI: 10.1089/tmj.2014.0153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emi Isaki
- Department of Communication Sciences and Disorders, Northern Arizona University, Flagstaff, Arizona
| | - Cynthia Fangman Farrell
- Department of Communication Sciences and Disorders, Northern Arizona University, Flagstaff, Arizona
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27
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Lincoln M, Hines M, Fairweather C, Ramsden R, Martinovich J. Multiple stakeholder perspectives on teletherapy delivery of speech pathology services in rural schools: a preliminary, qualitative investigation. Int J Telerehabil 2015; 6:65-74. [PMID: 25945230 PMCID: PMC4353008 DOI: 10.5195/ijt.2014.6155] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to investigate stakeholders’ views on the feasibility and acceptability of a pilot speech pathology teletherapy program for children attending schools in rural New South Wales, Australia. Nine children received speech pathology sessions delivered via Adobe Connect® web-conferencing software. During semi-structured interviews, school principals (n = 3), therapy facilitators (n = 7), and parents (n = 6) described factors that promoted or threatened the program’s feasibility and acceptability. Themes were categorized according to whether they related to (a) the use of technology; (b) the school-based nature of the program; or (c) the combination of using technology with a school-based program. Despite frequent reports of difficulties with technology, teletherapy delivery of speech pathology services in schools was highly acceptable to stakeholders. However, the use of technology within a school environment increased the complexities of service delivery. Service providers should pay careful attention to planning processes and lines of communication in order to promote efficiency and acceptability of teletherapy programs.
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Affiliation(s)
- Michelle Lincoln
- FACULTY OF HEALTH SCIENCES, THE UNIVERSITY OF SYDNEY, SYDNEY, AUSTRALIA
| | - Monique Hines
- FACULTY OF HEALTH SCIENCES, THE UNIVERSITY OF SYDNEY, SYDNEY, AUSTRALIA
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28
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Keck CS, Doarn CR. Telehealth Technology Applications in Speech-Language Pathology. Telemed J E Health 2014; 20:653-9. [DOI: 10.1089/tmj.2013.0295] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Casey Stewart Keck
- Department of Communication Sciences and Disorders, College of Allied Health, University of Cincinnati, Cincinnati, Ohio
| | - Charles R. Doarn
- Department of Family and Community Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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29
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Kelchner L. Telehealth and the Treatment of Voice Disorders: A Discussion Regarding Evidence. ACTA ACUST UNITED AC 2013. [DOI: 10.1044/vvd23.3.88] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Telehealth is becoming a major component of healthcare delivery and consumption. Although it has a substantial history internationally and within certain U.S. health sectors (e.g., military, transport medicine, home health care), widespread application to broader populations of U.S. health care consumers has taken place within only the last decade. Telehealth permits increased access to care, particularly for rural and underserved populations (Mashima & Doarn, 2008). Additional benefits include improved convenience, reduced healthcare costs, and greater opportunity for supported self-management in the patient’s own environment. Moreover, given the use of technology to manage all other aspects of personal life, the health care consumer should expect that medicine and allied health will make progress toward adapting their traditional models of care to more effective and efficient methods.
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Affiliation(s)
- Lisa Kelchner
- Department of Communication Sciences and DisordersUniversity of CincinnatiCincinnati, OH
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