Tele-rheumatology: telephone follow up and cyberclinic

Telerheumatology: A Systematic Review

OBJECTIVE

To identify and summarize the published and gray literature on the use of telemedicine for the diagnosis and management of inflammatory and/or autoimmune rheumatic disease.

METHODS

We performed a registered systematic search (CRD42015025382) for studies using MEDLINE (1946 to July 2015), Embase (1974 to July 2015), Web of Science (1900 to July 2015), and Scopus (1946 to July 2015) databases. We included studies that demonstrated the use of telemedicine for diagnosis and/or management of inflammatory/autoimmune rheumatic disease. Following data extraction, we performed a descriptive analysis.

RESULTS

Our literature search identified 1,468 potentially eligible studies. Of these studies, 20 were ultimately included in this review. Studies varied significantly in publication type, quality of evidence, and the reporting of methods. Most demonstrated a high risk of bias. Rheumatoid arthritis was the most commonly studied rheumatic disease (42% of patients). Studies demonstrated conflicting results regarding the effectiveness of telemedicine (18 found it effective, 1 found it effective but possibly harmful, and 1 found it ineffective). A limited number of studies included some component of a cost analysis (n = 6; 16% of patients); all of these found telemedicine to be cost-effective.

CONCLUSION

Studies identified by this systematic review generally found telemedicine to be effective for the diagnosis and management of autoimmune/inflammatory rheumatic disease; however, there is limited evidence to support this conclusion. Further studies are needed to determine the best uses of telemedicine for the diagnosis and management of these conditions.

Skype clinics after intestinal transplantation - follow-up beyond post codes

The follow-up after intestinal transplantation (ITX) is complex and limited to specialized centers. ITX recipients often travel all over the country to be seen in the outpatient clinic of specialized centers which is costly and time-consuming. Videoconferences through Skype have been implemented to eliminate travel time, costs, and to improve patient compliance without jeopardizing safety. Eighteen of 19 patients followed up after ITX or modified multivisceral transplantation (MMVTX) in conventional outpatient clinics in Oxford agreed to attend additional Skype clinics. All patients who were followed up through Skype clinics after ITX/MMVTX received a questionnaire to measure their satisfaction with methods and technical aspects of videoconferencing as well as time/mode of traveling, travel expenses/costs, waiting time in outpatient clinic and patients' satisfaction. Mean travel distance to Oxford was 236 ± 168 miles, mean travel time was 277 ± 175 min, and mean travel cost was 200 ± 56 Great Britain Pounds. A total of 56% had to take time off work and/or find child/family care for the time spent in travel. These patients reported a satisfaction score of 4.38 ± 0.77 of 5 points as opposed to 2.88 ± 0.90 for attending the conventional outpatient clinic. Skype clinics have been proven successful and feasible in highly specialized fields like ITX in eligible patients.

Post-operative care through tele-follow up visits in patients undergoing thyroidectomy and parathyroidectomy in a resource-constrained environment

We conducted a pilot study to assess the feasibility of tele-follow up in post-operative cases of thyroid and parathyroid diseases. Patients were enrolled after operation at the tertiary hospital in Lucknow who consented to report to the telemedicine centre at Cuttack, approximately 1500 km away. Initially videoconferencing used a single ISDN line (128 kbit/s); subsequently a satellite-based connection (384 kbit/s) was employed. Patients were given a questionnaire to assess their satisfaction with tele-follow up and the financial and work-time savings incurred by them. Over a period of nearly four years, a total of 34 postoperative patients were followed up by telemedicine. A total of 66 tele-visit sessions were held. The average number of visits per patient was two (range 1-6). The nature of disease was benign in 17 patients and malignant in the other 17. The reasons for tele-follow up were: confirmation of histology report (n = 18), medication dosage adjustments (n = 24) and serum thyroglobulin monitoring (n = 5). The patients' level of satisfaction was very good (31%) or excellent (69%). There were substantial financial and work-time savings per visit. Tele-follow up is feasible after thyroid and parathyroid surgery for benign thyroid and parathyroid disorders and in patients with low-risk thyroid cancers. The technique ensures satisfactory postoperative follow-up.

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

An evaluation of nurse-led rheumatology telephone clinics

AIMS AND OBJECTIVES

The aim of the study was to examine the impact on waiting times and patient satisfaction of nurse-led rheumatology telephone clinics.

METHODS

Patients awaiting outpatient review were contacted by the rheumatology clerk and offered a nurse-led rheumatology telephone appointment. Those who accepted were given a date and time for the appointment. A telephone consultation proforma was used to structure the call and to organize appropriate investigations/action. A questionnaire was mailed to the 68 patients reviewed during the first month of the telephone clinics to assess satisfaction. Status forms were also completed to record further action.

RESULTS

Of the 68 patients surveyed 73% completed and returned the questionnaire. Overall 72% were happy with the telephone consultation and would be happy to use the service again. Waiting times were reduced by two months as a total of 169 patients were reviewed during the April to August period.

CONCLUSION

Nurse-led telephone consultation, as part of chronic disease management, can be extremely beneficial for all rheumatology patients as a high level of satisfaction was achieved. In addition telephone consultations have helped to reduce the follow-up waiting times within the department by two months. This audit shows that telephone appointments conducted by an experienced nurse using an assessment proforma can be incorporated into routine follow-up care.