Expert Advice Provided through Telemedicine Improves Healing of Chronic Wounds: Prospective Cluster Controlled Study

Store-and-forward (asynchronous) doctor-to-dermatologist non-skin cancer specific teledermatology services in Australia: A scoping review

Store-and-forward teledermatology (SAFT) has become increasingly popular as a means to increase access to specialist care and address healthcare disparities such as those experienced by rural communities. A contemporary systematic overview of the Australian SAFT services and outcomes for all dermatological conditions is missing. This scoping review provides an overview of Australian SAFT models. Twelve studies were identified through web databases, grey literature sites and reference lists of eligible articles. Eligibility criteria included studies evaluating doctor-to-dermatologist Australian SAFT services provided to Australians for all skin conditions but excluded the studies that solely focused on skin cancers. Data on study design, setting, population, SAFT model, referral characteristics, patient, and general practitioner perspectives, diagnostic concordance, and measured outcomes such as follow up, investigation and waiting time were extracted. Quality of the included studies was assessed using CASP tools. Synthesis reveals that SAFT can be used for patients with any dermatological condition, provides more accurate diagnostics compared to cases without dermatologist input, may reduce waiting times for dermatological expertise, and users generally had positive experiences with SAFT. Although results are positive, this review reveals the heterogenous nature of the literature on SAFT in Australia and a need to establish a uniform approach to assessing the outcomes and impacts of such services.

Telemonitoring Wound Recovery with Smartphone: An Italian Experience during Pandemic Period

An important problem of plastic surgeons is monitoring wound healing, loss of substance, and postsurgical scar in different pathologies of the skin. Face to face monitoring is expensive and cannot be performed in periods of social crisis such as the recent COVID-19 pandemic. The use of telemedicine techniques is rising in this field of healthcare, promising the same results as the standard follow-up with more flexibility and savings. The purpose of this case study was to evaluate the effectiveness of remote monitoring and treatment through remote follow-up using digital applications. We followed up 25 patients with postoperative or diabetic ulcers for a period of 6 months (ranging from 2 to 6 months). We have performed clinical assessments using the Scar Cosmesis Assessment and Rating scale, and we have measured patient satisfaction using questionnaires. We chose to use the application for smartphone, describing the types of ulcers, number and average consultations, and the type of recovery, whether partial or complete. Monitoring wound recovery was very easy, and the patients found the experience very satisfactory. The total number of consultations was 255 with a significant reduction in outpatient visits during the pandemic period. Telemedicine is a useful tool in wound management and can be used to provide an optimal health care service with no inferior results to standard care.

Construction and Validation of an Image Discrimination Algorithm to Discriminate Necrosis from Wounds in Pressure Ulcers

Artificial intelligence (AI) in medical care can raise diagnosis accuracy and improve its uniformity. This study developed a diagnostic imaging system for chronic wounds that can be used in medically underpopulated areas. The image identification algorithm searches for patterns and makes decisions based on information obtained from pixels rather than images. Images of 50 patients with pressure sores treated at Kobe University Hospital were examined. The algorithm determined the presence of necrosis with a significant difference (p = 3.39 × 10−5). A threshold value was created with a luminance difference of 50 for the group with necrosis of 5% or more black pixels. In the no-necrosis group with less than 5% black pixels, the threshold value was created with a brightness difference of 100. The “shallow wounds” were distributed below 100, whereas the “deep wounds” were distributed above 100. When the algorithm was applied to 24 images of 23 new cases, there was 100% agreement between the specialist and the algorithm regarding the presence of necrotic tissue and wound depth evaluation. The algorithm identifies the necrotic tissue and wound depth without requiring a large amount of data, making it suitable for application to future AI diagnosis systems for chronic wounds.

Principles of extramural health care for chronic wounds in China

Development of extramural health care for chronic wounds is still in its infancy in China, and thus it is urgent and vital to establish a correct concept and practicable principles. The authors reviewed recent domestic and international literature and summarized the following treatment procedures and principles for extramural health care of chronic wounds. (1) The patient needs to do self-assessment of the wound by using available simple methods; (2) The patient consult with professional physicians or nurses on wound care to define the severity and etiology of the non-healing wound; (3) Professionals evaluate the existing treatment strategies; (4) Etiological treatments are given by professionals; (5) Patients buy needed dressings via the more convenient ways from pharmacies, e-commerce platform or others; (6) Professionals provide a standardized and reasonable therapeutic plan based on the patient's wound conditions; (7) Both professionals and the patient pay attention to complications to prevent adverse outcomes; (8) Professionals strengthen the public education on wound care and integrated rehabilitation. This review expected to provide new perspectives on the therapeutic strategies for chronic wounds in an extramural setting.

The viability and acceptability of a Virtual Wound Care Command Centre in Australia

The objective of this study was to assess the viability and acceptability of an innovative Virtual Wound Care Command Centre where patients in the community, and their treating clinicians, have access to an expert wound specialist service that comprises a digitally enabled application for wound analysis, decision-making, remote consultation, and monitoring. Fifty-one patients with chronic wounds from 9 centres, encompassing hospital services, outpatient clinics, and community nurses in one metropolitan and rural state in Australia, were enrolled and a total of 61 wounds were analysed over 7 months. Patients received, on average, an occasion of service every 4.4 days, with direct queries responded to in a median time of 1.5 hours. During the study period, 26 (42.6%) wounds were healed, with a median time to healing of 66 (95% CI: 56-88) days. All patients reported high satisfaction with their wound care, 86.4% of patients recommended the Virtual Wound Care Command Centre with 84.1% of patients reporting the digital wound application as easy to use. Potential mean travel savings of $99.65 for rural patients per visit were recognised. The data revealed that the Virtual Wound Care Command Centre was a viable and acceptable patient-centred expert wound consultation service for chronic wound patients in the community.

Outcomes of Telehealth for Wound Care: A Scoping Review

OBJECTIVE

To synthesize the literature on delivering wound care via telehealth and compare clinical, healthcare utilization, and cost outcomes when wound care is provided via telehealth (telewound) modalities compared with in-person care.

DATA SOURCES

An electronic search of PubMed, CINAHL, and Cochrane Clinical Trials databases for articles published from 1999 to 2019 was conducted using the following MeSH search terms: telewound, wound, wound care, remote care, telehealth, telemedicine, eHealth, mobile health, pressure injury, and ulcer.

STUDY SELECTION

Articles were included if they were a scientific report of a single study; evaluated a telehealth method; identified the type of wound of focus; and provided data on clinical, healthcare utilization, or cost outcomes of telewound care. In total, 26 articles met these criteria.

DATA EXTRACTION

Data were extracted and grouped into 13 categories, including study design, wound type, telehealth modality, treatment intervention, and outcomes measured, among others.

DATA SYNTHESIS

Of the 26 studies, 19 reported on clinical outcomes including overall healing and healing time; 17 studies reported on healthcare utilization including hospitalizations and length of stay; and 12 studies reported costs.

CONCLUSIONS

Evidence regarding the use of telewound care is weak, and findings related to the impact of telewound care on outcomes are inconsistent but indicate that it is not inferior to in-person care. Greater use of telehealth as a result of the COVID-19 pandemic points to further development of navigation and education models of telehealth for wound care. However, additional studies using rigorous research design and leveraging robust sample sizes are needed to demonstrate value.

Digitale Zukunft als Chance – Teledermatologie-Erfahrungen aus der Praxis

Hintergrund Verbesserte regulatorische Rahmenbedingungen und die Corona-Pandemie als Katalysator für die Digitalisierung im Gesundheitssystem haben zu einem umfassenden telemedizinischen Angebot geführt. Auf die Dermatologie entfällt dabei ein Drittel der telemedizinischen Leistungen. Die Ausgestaltung der teledermatologischen Leistung variiert dabei je nach Anbieter stark. Die Unterschiede sowie Vor- und Nachteile sind dabei sowohl für Ärztinnen und Ärzte als auch für Patientinnen und Patienten oftmals nicht ersichtlich.

Fragestellung Das Ziel des Beitrags ist daher, einen Überblick zu den Formen und aktuellen Einsatzgebieten der Teledermatologie zu schaffen. Darüber hinaus sollen die Einsatzmöglichkeiten der Anwendungsgebiete in der Teledermatologie eingeordnet werden und anhand von persönlichen Erfahrungen mit einer dermatologischen Telemedizin-Plattform exemplarisch beschrieben werden.

Material und Methode Zur Darstellung der Teledermatologie in Deutschland wurde eine Übersichtsarbeit erstellt, die aktuelle nationale und internationale Studien und Befragungen zum Einsatz der Teledermatologie umfasst. Die exemplarische Vorstellung der asynchronen Teledermatologie am Beispiel des Angebots „OnlineDoctor“ erfolgt anhand von qualitativen Interviews der Autoren mit teilnehmenden Dermatologinnen und Dermatologen sowie öffentlich zugänglichen Produktinformationen.

Ergebnisse In einem Großteil der dermatologischen Fälle ist eine hohe Konkordanz der Diagnose und Patientenzufriedenheit unter Nutzung teledermatologischer Anwendungen erkennbar. Sowohl im Kontext der Diagnosestellung als auch bei der Versorgung chronischer Patientinnen und Patienten und dem Triagieren sind die Vorteile evaluiert. Dabei weisen die verschiedenen teledermatologischen Verfahren insbesondere mit Blick auf die genutzte Technologie (synchron bzw. asynchron) große Unterschiede auf. Die Vorteile der asynchronen Teledermatologie liegen dabei primär in der zeitlichen und örtlichen Flexibilität sowie dem breiten Anwendungsspektrum. Versorgungsdaten aus dem Alltag der beiden Autoren stützen die Aussage, dass Teledermatologie bei gleicher medizinischer Qualität positive Effekte für Patientinnen und Patienten sowie Praxen hat.

Diskussion Die Teledermatologie hat das Potenzial, Prozesse in Praxen zu verbessern und näher an der Patientin und dem Patienten zu arbeiten. Dabei ist unter dem Stichwort „Patient Empowerment“ eine patientenzentrierte Medizin anzustreben und die Möglichkeiten der digitalen Anwendungen sind zu nutzen. Die Autoren gehen davon aus, dass sich in den kommenden Jahren sowohl die Indikationen, die via Telemedizin diagnostiziert werden können, als auch die Einsatzfelder erweitern werden. Die Zukunft wird eine weitere Individualisierung des digitalen Angebotes ermöglichen und die kombinierte Nutzung von digitalen Tools und analogen Untersuchungen in der Praxis zum Goldstandard werden lassen.

[Areas of application for teledermatology]

Hintergrund

In den letzten Jahren wurden mit dem E‑Health-Gesetz und der Lockerung des Fernbehandlungsverbotes die Rahmenbedingungen für die Telemedizin in Deutschland verbessert.

Fragestellung

Das Ziel dieses Beitrags ist es, eine Übersicht wichtiger Anwendungsgebiete der Teledermatologie darzustellen.

Material und Methode

Erstellt wurde eine narrative Übersichtsarbeit von nationalen und internationalen Studien und Projekten zum Einsatz der Teledermatologie für die Diagnosestellung, die Verlaufskontrolle, die Triage zwischen Haus- und Hautärzten sowie den Einsatz in Einrichtungen mit organisatorisch und/oder geografisch erschwertem Zugang zu fachmedizinischer Versorgung.

Ergebnisse

Diagnostische Anwendungen ermöglichen in einem Großteil der Fälle die teledermatologische Beurteilung bei hoher Konkordanz der Diagnose und Patientenzufriedenheit. In der Versorgung chronischer Patienten wurde in der Mehrzahl von Studien nachgewiesen, dass kein Unterschied in der Effektivität der Behandlung zwischen der Präsenz- und Fernbehandlung vorliegt und Patienten Anfahrtswege und Wartezeiten einsparen. Bei dermatologischen Fällen, die mithilfe der Teletriage evaluiert wurden, konnte ein Großteil beim Hausarzt verbleiben. Gleichzeitig wurden Patienten identifiziert, die schnellstmöglich beim Hautarzt vorstellig werden sollten. In besonderen Einrichtungen wie Justizvollzugsanstalten werden dermatologische Telekonsile erfolgreich eingesetzt.

Diskussion

Für die Nutzung der Teledermatologie in Deutschland liegen hinreichende Rahmenbedingungen und eine befriedigende Evidenz vor. Die Anwendungsbereiche sind detailliert in der S2k-Leitlinie der Teledermatologie abgebildet. Es besteht das Risiko, dass der Zugang zur Telemedizin für bestimmte Bevölkerungsgruppen erschwert sein könnte.

Right siting of complex acute wound management---preliminary study of teleconsultation wound services between acute and primary care in Singapore

This study aimed to provide preliminary evidence on feasibility of the inaugural use of teleconsultation between acute hospitals and primary care for acute wound management in Singapore. Post-surgical patients with carbuncle wounds, perianal abscess wounds or surgical abdominal dehiscence wounds were recruited from an acute hospital. Instead of receiving their follow up care at the acute care tertiary hospital, patients were given the option to receive their care at primary care facilities instead, supported by teleconsultation wound services provided by wound care nurses from the hospital. The following outcome measures were collected: number of care sessions required (until wound healed), readmissions or referrals back to hospital, cost (patient's and healthcare provider's perspective), patients' and nurses' satisfaction. In total, 18 patients were recruited and completed the study (teleconsult group = 5; tertiary care clinic group = 13). The mean age (SD) of patients were 63.2 (SD 11.5) years old in the teleconsult group and 47.9 years old (SD 11.5) in the tertiary care clinic group. There were 7 female (54%), and 6 male (46%) in the tertiary care clinic group whereas teleconsult group consisted of male only (n = 5). Most had carbuncle wounds (teleconsult group: n = 4; 80%); tertiary care clinic group: (n = 10; 77%). For patients with carbuncle wounds, the average number of care sessions required were 21 and 33 for the tertiary care clinic and teleconsult respectively. None of the patients in the teleconsult group were referred back to the tertiary care hospital. All 16 nurses (n = 6 from acute care hospital, n = 10 from polyclinics) who participated in the feedback survey cited convenience, ease of tracking wound sizes, and closer collaboration between the acute care and primary care nurses as advantages of the service. Wound teleconsultation is feasible and potentially cost savings for patients with acute complex wounds.

Wound Image Quality From a Mobile Health Tool for Home-Based Chronic Wound Management With Real-Time Quality Feedback: Randomized Feasibility Study

Background

Travel to clinics for chronic wound management is burdensome to patients. Remote assessment and management of wounds using mobile and telehealth approaches can reduce this burden and improve patient outcomes. An essential step in wound documentation is the capture of wound images, but poor image quality can have a negative influence on the reliability of the assessment. To date, no study has investigated the quality of remotely acquired wound images and whether these are suitable for wound self-management and telemedical interpretation of wound status.

Objective

Our goal was to develop a mobile health (mHealth) tool for the remote self-assessment of digital ulcers (DUs) in patients with systemic sclerosis (SSc). We aimed to define and validate objective measures for assessing the image quality, evaluate whether an automated feedback feature based on real-time assessment of image quality improves the overall quality of acquired wound images, and evaluate the feasibility of deploying the mHealth tool for home-based chronic wound self-monitoring by patients with SSc.

Methods

We developed an mHealth tool composed of a wound imaging and management app, a custom color reference sticker, and a smartphone holder. We introduced 2 objective image quality parameters based on the sharpness and presence of the color checker to assess the quality of the image during acquisition and enable a quality feedback mechanism in an advanced version of the app. We randomly assigned patients with SSc and DU to the 2 device groups (basic and feedback) to self-document their DU at home over 8 weeks. The color checker detection ratio (CCDR) and color checker sharpness (CCS) were compared between the 2 groups. We evaluated the feasibility of the mHealth tool by analyzing the usability feedback from questionnaires, user behavior and timings, and the overall quality of the wound images.

Results

A total of 21 patients were enrolled, of which 15 patients were included in the image quality analysis. The average CCDR was 0.96 (191/199) in the feedback group and 0.86 (158/183) in the basic group. The feedback group showed significantly higher (P<.001) CCS compared to the basic group. The usability questionnaire results showed that the majority of patients were satisfied with the tool, but could benefit from disease-specific adaptations. The median assessment duration was <50 seconds in all patients, indicating the mHealth tool was efficient to use and could be integrated into the daily routine of patients.

Conclusions

We developed an mHealth tool that enables patients with SSc to acquire good-quality DU images and demonstrated that it is feasible to deploy such an app in this patient group. The feedback mechanism improved the overall image quality. The introduced technical solutions consist of a further step towards reliable and trustworthy digital health for home-based self-management of wounds.

[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.

Machine learning models for synthesizing actionable care decisions on lower extremity wounds

Lower extremity chronic wounds affect 4.5 million Americans annually. Due to inadequate access to wound experts in underserved areas, many patients receive non-uniform, non-standard wound care, resulting in increased costs and lower quality of life. We explored machine learning classifiers to generate actionable wound care decisions about four chronic wound types (diabetic foot, pressure, venous, and arterial ulcers). These decisions (target classes) were: (1) Continue current treatment, (2) Request non-urgent change in treatment from a wound specialist, (3) Refer patient to a wound specialist. We compare classification methods (single classifiers, bagged & boosted ensembles, and a deep learning network) to investigate (1) whether visual wound features are sufficient for generating a decision and (2) whether adding unstructured text from wound experts increases classifier accuracy. Using 205 wound images, the Gradient Boosted Machine (XGBoost) outperformed other methods when using both visual and textual wound features, achieving 81% accuracy. Using only visual features decreased the accuracy to 76%, achieved by a Support Vector Machine classifier. We conclude that machine learning classifiers can generate accurate wound care decisions on lower extremity chronic wounds, an important step toward objective, standardized wound care. Higher decision-making accuracy was achieved by leveraging clinical comments from wound experts.

Modified telehealth for care of chronic wounds during the Coronavirus disease 2019 pandemic: A rapid literature review of alternative care modalities

Due to the changes in delivering medical care during the Coronavirus disease 2019 (COVID-19) pandemic, such as the heavy reliance on telehealth, it is worth exploring if this is suitable when treating complex wounds. A literature rapid review was performed to explore the existing evidence around alternative service delivery modalities. While there are organisations that have successful telehealth systems and infrastructure, for services that do not already widely use telehealth it is difficult to implement a standardised system in the current state of emergency. The evidence reviewed demonstrates that telehealth appears to currently have a limited place in chronic wound management; therefore, standardisation on determining suitability in conjunction with evaluation of telehealth during this period is needed to shape implementation of telehealth systems in the future.

Telemedicine and the COVID-19 Pandemic: Are We Ready to Go Live?

Telemedicine use in the field of wound care had been increasing in popularity when the novel coronavirus 2019 paralyzed the globe in early 2020. To combat the constraints of healthcare delivery during this time, the use of telemedicine has been further expanded. Though many limitations of telemedicine are still being untangled, the benefits of virtual care are being realized in both inpatient and outpatient settings. In this article, the advantages and disadvantages of telemedicine are discussed through two case examples that highlight the promise of implementation during and beyond the pandemic.

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation

BACKGROUND

Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation.

OBJECTIVE

This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA.

METHODS

We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs.

RESULTS

This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310).

CONCLUSIONS

Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20139.

Telemedicine in Chronic Wound Management: Systematic Review And Meta-Analysis

BACKGROUND

Chronic wounds have been a great burden to patients and the health care system. The popularity of the internet and smart devices, such as mobile phones and tablets, has made it possible to adopt telemedicine (TM) to improve the management of chronic wounds. However, studies conducted by different researchers have reported contradictory results on the effect of TM on chronic wound management.

OBJECTIVE

The aim of this work was to evaluate the efficacy and safety of TM in chronic wound management.

METHODS

We systematically searched multiple electronic databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials [CENTRAL]) to identify eligible studies published from inception to June 12, 2019. Inclusion criteria were randomized controlled trials (RCTs) and interventional cohort studies that investigated the use of TM in chronic wound management. RCT and observational data were analyzed separately. A meta-analysis and qualitative analysis were conducted to estimate endpoints.

RESULTS

A total of 6 RCTs and 6 cohort studies including 3913 patients were included. Of these, 4 studies used tablets or mobile phones programmed with apps, such as Skype and specialized interactive systems, whereas the remaining 8 studies used email, telephone, and videoconferencing to facilitate the implementation of TM using a specialized system. Efficacy outcomes in RCTs showed no significant differences in wound healing (hazard ratio [HR] 1.16, 95% CI 0.96-1.39; P=.13), and wound healing around 1 year (risk ratio [RR] 1.05, 95% CI 0.89-1.23; P=.15). Noninferiority criteria of TM were met. A decreased risk of amputation in patients receiving TM was revealed (RR 0.45, 95% CI 0.29-0.71; P=.001). The result of cohort studies showed that TM was more effective than standard care (HR 1.74, 95% CI 1.43-2.12; P<.001), whereas the outcome efficacy RR of wound healing around 1 year (RR 1.21, 95% CI 0.96-1.53; P=.56) and 3 months (RR 1.24, 95% CI 0.47-3.3; P=.67) was not significantly different between TM and standard care. Noninferiority criteria of TM were met for wound healing around 1 year in cohort studies.

CONCLUSIONS

Currently available evidence suggests that TM seems to have similar efficacy and safety, and met noninferiority criteria with conventional standard care of chronic wounds. Large-scale, well-designed RCTs are warranted.

Complex Wound Healing Outcomes for Outpatients Receiving Care via Telemedicine, Home Health, or Wound Clinic: A Randomized Controlled Trial

Use of telemedicine has expanded rapidly in recent years, yet there are few comparative studies to determine its effectiveness in wound care. To provide experimental data in the field of telemedicine with regard to wound care, a pilot project named “Domoplaies” was publicly funded in France in 2011. A randomized, controlled trial was performed to measure the outcomes of patients with complex wounds who received home wound care from a local clinician guided by an off-site wound care expert via telemedicine, versus patients who received in-home or wound clinic visits with wound care professionals. The publicly funded network of nurses and physicians highly experienced in wound healing was used to provide wound care recommendations via telemedicine for the study. The healing rate at 6 months was slightly better for patients who received wound care via telemedicine (61/89; 68.5%) versus wound care professional at home (38/59; 64.4%) versus wound care clinic (22/35; 62.9%), but the difference was not significant ( P = .860833). The average time to healing for the 121/183 wounds that healed within 6 months was 66.8 ± 32.8 days for the telemedicine group, 69.3 ± 26.7 for the wound care professional at home group, and 55.8 ± 25.0 days for the wound care clinic group. Transportation costs for the telemedicine and home health care groups were significantly lower than the wound clinic group, and death rate was similar between all the 3 groups ( P < .01). Telemedicine performed by wound healing clinicians working in a network setting offered a safe option to remotely manage comorbid, complex wound care patients with reduced mobility.

[Teleconsultation for vascular- and diabetes-associated chronic wounds : A systematic review of health-related and economic implications]

BACKGROUND

In addition to lowering the quality of life of those affected, long periods of treatment and high recurrence rates of chronic wounds cause major economic costs for health care systems. Furthermore, inadequate health care and undersupply of care can be observed in Germany. Thus, new forms of care such as teleconsultation are being discussed increasingly. Recent changes in the remuneration system and macerations in the ban of remote treatment support those trends.

METHODS

A systematic review was conducted in July 2018 using PubMed and CENTRAL databases for randomized controlled trials between 2008 and 2018. Only randomized clinical trials in which patients with chronic wound who received treatment and follow-up by teleconsultation using information and communication technology to share data were included. In total, 6 international clinical trials were identified.

RESULTS

Regarding the current state of research, there is no definite evidence that teleconsultation can improve the care of chronic wound patients. Most likely, wound healing time was positively influenced. No correlation was found between mortality and hospitalizations when teleconsultation was used.

CONCLUSION

On the basis of the included studies, the evidence for the care of chronic wounds by teleconsultation is unclear. Further research is needed to examine the health-related and economic benefits of teleconsultation to support integration into health care systems.

How NPs can help expand telehealth services

Consumers of healthcare services are demanding more convenient and accessible options to care. Technologic advancements can support this demand, but telehealth knowledge is lacking. This article will describe the current state of telehealth and examine the role that NPs can play in furthering its adoption.

Evaluating healthcare practitioners' views on store-and-forward teledermoscopy services for the diagnosis of skin cancer

Objective

The aim of the study is to evaluate healthcare practitioners’ views on and satisfaction with (i) digital image acquisition and storage and (ii) store-and-forward teledermoscopy services for the diagnosis of skin cancer in their clinical practice.

Methods

An online survey was conducted among 59 healthcare practitioners (GPs (n=17), dermatologists (n=22), dermatology registrars (n=18), a dermatology research fellow (n=1) and a plastic surgeon (n=1)) to assess usability of digital image acquisition and storage for when the imaging process is conducted by the healthcare practitioners themselves, or by their patients. The study identifies the enablers and barriers of this emerging mode of medical practice. A thematic analysis was used to extract key themes from open-ended responses, which involved identifying themes and patterns within and across participants.

Results

Thirty-four healthcare practitioners (58%) had previously used a mobile dermatoscope within their practice. Participants most appreciated its use in their practice for lesion monitoring (59%) and record keeping (39%). Challenges reported were the increased time to support the additional workload (45%), technical issues (33%) and cost of equipment (27%). Practitioners were unsure (36%) or did not advocate teledermoscopy for direct-to-consumer use (41%). Only 23% supported the use of direct-to-consumer teledermoscopy.

Conclusion

While most practitioners are receptive to mobile teledermoscopy, there was less support for patient-initiated use, whereby the patient controls the imaging process. As technology improves rapidly it is important to evaluate practitioners’ acceptance and satisfaction of evolving telehealth services, moving forward with models of practice where healthcare practitioners and other healthcare providers will feel comfortable engaging in telehealth services.

Organisation of health services for preventing and treating pressure ulcers

BACKGROUND

Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment.

OBJECTIVES

To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers.

SEARCH METHODS

In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence.

MAIN RESULTS

The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low.

AUTHORS' CONCLUSIONS

Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

REAL-WORLD CLINICAL EVALUATION AND COSTS OF TELEMEDICINE FOR CHRONIC WOUND MANAGEMENT

BACKGROUND

Chronic wounds are frequent, affect quality of life, and increase care costs. Telemedicine provides potential for effective wound care management, especially for the monitoring of complex wounds at home.

OBJECTIVES

The objective of the present study was to determine the clinical effects and costs of telemedicine for the follow-up of complex chronic wounds from the perspective of the public health insurance. The study ran over a period of 9 months.

METHODS

We conducted a prospective, pragmatic, open-label, observational study and carried out a cost-effectiveness analysis. A total of 116 patients with chronic wounds were assigned to their choice of two groups: telemedicine (N = 77) and traditional follow-up (control; N = 39). The primary outcome was the time to healing. Secondary outcomes included percentage of wounds reaching target objective, percentage of wounds healed completely, outpatient care costs, travel costs, and hospitalizations.

RESULTS

Time to healing was shorter in the telemedicine group than in the control group (137 versus 174 days; p .05). Outpatient care and hospitalization costs were not significantly different. The main results in terms of economic savings were medical transport costs reimbursed by the French public health insurance, which were significantly lower in the telemedicine group. Telemedicine costs were found to be €4,583 less per patient compared with standard practice over 9 months.

CONCLUSIONS

This trial suggests that telemedicine saves travel costs and results in a shorter healing time than traditional follow-up.

Teleburn: Designing A Telemedicine Application to Improve Burn Treatment

Background

Due to the increasing rate of the burn injuries and a limited number of specialized treatment centers, providing medical advice and medical care at the point of need is necessary. The aim of the present study was to design and implement a teleburn system to enhance the quality of care for the burn patients.

Methods

This study was completed in 2016. In order to design the system, information needs assessment was conducted by using a questionnaire. The participants of this phase were five specialists, five general practitioners, and 12 nurses. The setting of the study was the burn department of a public hospital and a burn center. The prototype of the system was designed based on the findings derived from the first phase, and the usability of the system was evaluated later.

Results

The teleburn system was a web-based system with different sections for GPs/nurses and specialists. In total, 28 burn consultations were made successfully by using the system. The findings of the usability testing showed that most of the participants evaluated the system at a good level. The mean score for the specialists, general practitioners and nurses was 8.4±0.46, 7.7±0.39, and 7.5±0.51, respectively.

Conclusion

Although it was the first time in the country that the teleburn system was designed and introduced to the clinicians, they seemed to be satisfied with using the system. This system could help general practitioners and nurses to receive specialist's advice on a timely manner to improve the treatment of the burn patients. However, more research should be conducted to determine the effectiveness of using this technology in the real work environment.

Health Information Technology Continues to Show Positive Effect on Medical Outcomes: Systematic Review

Background

Health information technology (HIT) has been introduced into the health care industry since the 1960s when mainframes assisted with financial transactions, but questions remained about HIT’s contribution to medical outcomes. Several systematic reviews since the 1990s have focused on this relationship. This review updates the literature.

Objective

The purpose of this review was to analyze the current literature for the impact of HIT on medical outcomes. We hypothesized that there is a positive association between the adoption of HIT and medical outcomes.

Methods

We queried the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE) by PubMed databases for peer-reviewed publications in the last 5 years that defined an HIT intervention and an effect on medical outcomes in terms of efficiency or effectiveness. We structured the review from the Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and we conducted the review in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR).

Results

We narrowed our search from 3636 papers to 37 for final analysis. At least one improved medical outcome as a result of HIT adoption was identified in 81% (25/37) of research studies that met inclusion criteria, thus strongly supporting our hypothesis. No statistical difference in outcomes was identified as a result of HIT in 19% of included studies. Twelve categories of HIT and three categories of outcomes occurred 38 and 65 times, respectively.

Conclusions

A strong majority of the literature shows positive effects of HIT on the effectiveness of medical outcomes, which positively supports efforts that prepare for stage 3 of meaningful use. This aligns with previous reviews in other time frames.

The Effect of Telemedicine Follow-up Care on Diabetes-Related Foot Ulcers: A Cluster-Randomized Controlled Noninferiority Trial

OBJECTIVE

To evaluate whether telemedicine (TM) follow-up of patients with diabetes-related foot ulcers (DFUs) in primary health care in collaboration with specialist health care was noninferior to standard outpatient care (SOC) for ulcer healing time. Further, we sought to evaluate whether the proportion of amputations, deaths, number of consultations per month, and patient satisfaction differed between the two groups.

RESEARCH DESIGN AND METHODS

Patients with DFUs were recruited from three clinical sites in western Norway (2012-2016). The cluster-randomized controlled noninferiority trial included 182 adults (94/88 in the TM/SOC groups) in 42 municipalities/districts. The intervention group received TM follow-up care in the community; the control group received SOC. The primary end point was healing time. Secondary end points were amputation, death, number of consultations per month, and patient satisfaction.

RESULTS

Using mixed-effects regression analysis, we found that TM was noninferior to SOC regarding healing time (mean difference -0.43 months, 95% CI -1.50, 0.65). When competing risk from death and amputation were taken into account, there was no significant difference in healing time between the groups (subhazard ratio 1.16, 95% CI 0.85, 1.59). The TM group had a significantly lower proportion of amputations (mean difference -8.3%, 95% CI -16.3%, -0.5%), and there were no significant differences in the proportion of deaths, number of consultations, or patient satisfaction between groups, although the direction of the effect estimates for these clinical outcomes favored the TM group.

CONCLUSIONS

The results suggest that use of TM technology can be a relevant alternative and supplement to usual care, at least for patients with more superficial ulcers.

Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.

Validation of a Screening Questionnaire for Chronic Leg Ulcers

The use of a validated screening questionnaire to identify individuals with chronic leg ulcers allows large-scale population-based studies to be conducted that measure and monitor the prevalence of the disease. The aim of this study was to design and validate such a screening questionnaire to identify patients with chronic leg ulcers. A simple 3-item questionnaire was developed at the Department of Dermatology, University Hospital of Zealand, Denmark. In total, 90 patients attending the department’s outpatient clinic for dermatological diseases and chronic wounds were included in this study. All included participants completed the questionnaire and were subsequently examined by dermatologists. We found that the constructed 3-item questionnaire in this study had a sensitivity and specificity of 95% and 93% and a positive predictive value and negative predictive value of 78% and 95%, respectively. Moreover, we found that the use of the 3-item questionnaire, as compared with a single question, in which the participants were asked whether they currently have a leg ulcer, resulted in significantly higher positive predictive value (+11.6%, P = .035) and specificity (+5.6%, P = .046) of the diagnostic test. Future studies are merited to investigate the diagnostic accuracy of the questionnaire in other populations and settings.

Epidemiology and health care situation of chronic wounds in Germany

Chronic wounds are of great socioeconomic importance. Usually they are associated with a long, complicated and burdensome course of disease and require high nursing and medical expenses. The quality of life of patients with chronic wounds is substantially impaired. This article provides a systematic overview of current studies on the morbidity and the health care situation of patients with chronic wounds, especially in patients with leg ulcers in Germany.

Analyses based on routine data of statutory health insurances show higher incidence and prevalence rates, for example of patients with leg ulcers, compared with previously regional surveys. The quality of care is inadequate, particularly in diagnostics and therapy of patients with leg ulcers. To date, there is undersupply and a lack of execution and deficient knowledge about the compression treatment in patients with venous leg ulcers.

Thus, there is need for further action in order to establish better implementation of guidelines in the management of patients with chronic wounds.