A pilot study of a telehealth intervention for persons with spinal cord dysfunction

Needs Assessment of Self-Management for Individuals With Chronic Spinal Cord Injury/Disease

Since the 1980s, survivorship for persons with spinal cord injury/disease (SCI/D) has significantly improved; however, life expectancy remains lower than the general population due to secondary health conditions (SHCs) that lead to decreased function and death. This study explored (1) facilitators and barriers to engaging in self-management (SM) for persons with SCI/D and (2) stakeholder perspectives on potential SM program components and content for intervention development. Around 38 participants with SCI/D responded to this cross-sectional study and needs assessment conducted at the University of Missouri, Columbia. Responses were analyzed to determine descriptive statistics. Participants indicated barriers to SM include transportation/distance, presence of SHCs, and a lack of local resources. Participants noted that virtual SM programs with strong psychological health/coping components were preferred. These findings should guide the development of an SM program tailored to SCI/D to reduce the prevalence and impact of SHC on the SCI/D population.

The Effects of APP-Based Intervention for Depression Among Community-Dwelling Individuals With Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

To assess the effect of a self-management intervention delivered by mobile application (APP) for depression among community-dwelling individuals with spinal cord injury (SCI).

DESIGN

Randomized controlled trial.

SETTINGS

General communities in China.

PARTICIPANTS

Community-dwelling individuals with SCI who were diagnosed within 2 years were recruited in this study (N=98). It was a convenience sample with an average age of 41.71, 82.7% participants were men.

INTERVENTIONS

Participants in the intervention group (n=49) received 5 sessions on self-management training provided by nurse-led multidisciplinary team via APP at the second, fourth, sixth, eighth, and 12th weeks, respectively, after they discharge from hospitals. Participants in the control group (n=49) received routine telephone counselling provided by follow-up nurses at the 12th week after they discharge.

OUTCOME MEASURE

The outcome of this study is depression, which is not the primary outcomes in the registration of this program. Depression was measured by version 2 of Beck Depression Inventory at discharge (T₀), the 12th week after discharge from hospitals (T₁), and the 24th week after discharge from hospitals (T₂).

RESULTS

There were 98 participants (49 in the intervention group and 49 in the control group) completing the intervention and data collection. Compared with the control group, the intervention group had lower level of depression at T2 (B=-5.76; 95% CI=-9.97, -1.54; P=.007). Small to moderate effect sizes on depression favoring the intervention were demonstrated at T₁ (Cohen's d=-.178) and T₂ (Cohen's d=-.535).

CONCLUSIONS

APP-based self-management support can be a potential intervention to reduce depression among community-dwelling individuals with SCI.

Interventions, stakeholders, and organization related to pressure ulcer prevention for individuals with spinal cord injuries in transition from hospital to home - A scoping review

STUDY DESIGN

Scoping review.

AIM OF THE STUDY

To obtain an overview of initiatives, organisational components, and stakeholders' perspectives on PU prevention in transitional care.

METHODS

Scoping review searching the databases: MEDLINE, EMBASE), CINAHL, Cochrane Library, Web of Science, and SCOPUS in May 2022. Inclusion of English-written research on pressure ulcer prevention in adult people with spinal cord injury in transition from hospital or rehabilitation centre to the home care environment.

RESULTS

Fifteen studies of different types are included in this study: six qualitative studies, four randomized controlled trials, three cohort studies, one cross-sectional study and an interventional study. The included studies are relatively low-level evidence but of acceptable quality.

CONCLUSION

Continuous tailored education and information about PU prevention and follow-up services are essential components in preventing PUs and rehabilitating people with SCI. The complexity of SCI requires adaptations, equipment and access to specialist care and treatment after discharge. However, there is a discrepancy between the international recommendations, the perceived needs, and the delivered healthcare services. The consequences are a lower quality of life and a higher risk of PUs for people with SCI.

Communication between persons with multiple sclerosis and their health care providers: A scoping review

OBJECTIVES

This study undertakes a scoping review of research about communication between persons with MS and their health care providers.

DESIGN

PubMed, PsycInfo, Communication Source, Socindex, Sociological Abstracts, Cinahl, and Proquest Dissertations and Theses were used to identify studies since each database's inception. Research team members engaged in study selection, coding for communication issues, and data extraction for descriptive information.

RESULTS

Of the 419 empirical articles identified, 175 were included. Codes represented all elements of ecological and pathway models, emphasizing emerging technologies for facilitating communication, uncertainty and anxiety for persons with MS, and communication issues surrounding diagnosis, information seeking, and decision making.

CONCLUSION

This review synthesizes and organizes influences on communication, communication processes, and health outcomes of communication for persons with MS and their providers. Findings extend the ecological model with illness context and the pathway model with communication breakdowns and provider outcomes.

PRACTICE IMPLICATIONS

Health care providers should consider the complexity of communication when interacting with persons with MS, including the larger context in which it occurs, communication processes and their purposes, and short-term and long-term consequences of interactions. Ecological and pathway models can be frameworks for developing educational materials, as they succinctly capture key communication issues and outcomes.

Telemedicine for Preventing and Treating Pressure Injury after Spinal Cord Injury: A Systematic Review and Meta-analysis (Preprint)

Background

Objective

Methods

Results

Conclusions

Barriers and facilitators to changing bowel care practices after spinal cord injury: a Theoretical Domains Framework approach

BACKGROUND

Improvement to autonomic processes such as bladder, bowel and sexual function are prioritised by individuals with spinal cord injury (SCI). Bowel care is associated with high levels of dissatisfaction and decreased quality of life. Despite dissatisfaction, 71% of individuals have not changed their bowel care routine for at least 5 years, highlighting a disconnect between dissatisfaction with bowel care and changing routines to optimise bowel care.

OBJECTIVE

Using an integrated knowledge translation approach, we aimed to explore the barriers and facilitators to making changes to bowel care in individuals with SCI.

METHODS

Our approach was guided by the Behaviour Change Wheel and used the Theoretical Domains Framework (TDF). Semi-structured interviews were conducted with individuals with SCI (n = 13, mean age 48.6 ± 13.1 years) and transcribed verbatim (duration 31.9 ± 7.1 min). Barriers and facilitators were extracted, deductively coded using TDF domains and inductively analysed for themes within domains.

RESULTS

Changing bowel care after SCI was heavily influenced by four TDF domains: environmental context and resources (workplace flexibility, opportunity or circumstance, and access to resources); beliefs about consequences; social influences (perceived support and peer mentorship); and knowledge (knowledge of physiological processes and bowel care options). All intervention functions and policy categories were considered viable intervention options, with human (61%) and digital (33%) platforms preferred.

CONCLUSIONS

Modifying bowel care is a multi-factorial behaviour. These findings will support the systematic development and implementation of future interventions to both enable individuals with SCI to change their bowel care and to facilitate the optimisation of bowel care approaches.

The content and effectiveness of self-management support interventions for people at risk of pressure ulcers: A systematic review

BACKGROUND

Pressure ulcers are a common complication with a high impact on well-being and quality of life in people with impaired mobility and/or dysfunctional pain sensations. Prevention is therefore crucial. However, persons at risk seem to experience difficulties in adhering to self-management regimens that can help to prevent or diminish the development of pressure ulcers. Self-management support interventions might help to improve their self-management skills.

OBJECTIVES

To review the content, components and effectiveness of self-management support interventions on clinical and behavioral outcomes for people at risk of pressure ulcers.

METHODS

A systematic literature search for the period of January 2000 to February 2020 was conducted in five databases (CINAHL, Cochrane, PsycINFO, PubMed, and Web of Science). Inclusion criteria were: (1) studies including persons at a high risk of pressure ulcers; (2) studies investigating interventions focused on self-management support; (3) studies describing clinical and behavioral outcomes related to prevention and care of pressure ulcers. All studies were independently screened on title, abstracts and full text by two researchers. The PRISMS taxonomy of 14 components was used to code intervention content.

RESULTS

The search yielded 5297 papers, which resulted in the inclusion of 16 papers on self-management support interventions for persons at risk of pressure ulcers. Interventions focused mostly on 'Information about condition and/or management' (13 interventions), 'Training in practical self-management activities' (7 interventions), and 'Training in psychological strategies' (6 interventions). 'Provision of equipment' was not investigated. The intensity of the interventions varied in delivery mode, frequency and duration. Improvements were found in clinical outcomes in four studies and in behavioral outcomes in ten studies. Four studies showed improvements in clinical outcomes and ten studies in behavioral outcomes. Knowledge was positively influenced in eight studies.

CONCLUSION

Self-management support interventions show potential. The extensiveness and intensity of the interventions seem to be predictive for the effectiveness, but specific content components cannot be recommended. This review revealed recommendations for future research and international consensus should be reached about patient-relevant outcomes.

The Time Burden of Specialty Clinic Visits in Persons With Neurologic Disease: A Case for Universal Telemedicine Coverage

Objective: Those with chronic neurologic disorders are often burdened not only by the condition itself but also an increased need for subspecialty medical care. This may require long distance travel, while even small distances can be a hardship secondary to impaired mobility and transportation. We sought to examine the burden of time associated with clinical visits for those with chronic neurologic disorders and their family/caregivers. These topics are discussed as an argument to support universal coverage for telemedicine in this population.

Design: Cohort Study.

Setting: Specialty clinic at community hospital.

Participants: 208 unique patients with chronic neurologic disability at physical medicine and rehabilitation or neurourology clinic over a 3-month period.

Main Outcome Measures: Patient survey on commute distance, time, difficulties, and need for caregiver assistance to attend visits.

Results: Approximately 40% of patients were covered by Medicare. Many patients (42%) perceived it difficult to attend their clinic visit with transportation difficulties, commute time, and changes to their daily schedule being the most commonly cited reasons. Most patients (75%) lived within 25 miles of our clinics and experienced an average commute time of 79.4 min, though 10% required 3 h or more. Additional family/caregiver assistance was required for 76% of patients, which resulted in an inclusive average commute time of 138.2 min per patient.

Conclusion: Chronically neurologically-disabled patients and their caregivers may be burdened by the commute to outpatient appointments. To minimize this burden, increased emphasis on telemedicine coverage for those with chronic neurologic disability should be considered by all payors.

Patient and lay carer education for preventing pressure ulceration in at-risk populations

BACKGROUND

Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces. PUs cause pain, discomfort, longer hospital stays, and decreased quality of life. They are also very costly to treat and consume substantial parts of healthcare budgets. PUs are largely preventable, and education targeted at patients and their carers is considered important.

OBJECTIVES

To assess the effects of patient and/or lay carer education on preventing pressure ulceration in at-risk people, in any care setting.

SEARCH METHODS

In June 2019 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; Ovid PsycINFO and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies.  There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people of any age at risk of pressure ulceration, and RCTs that recruited people who informally care for someone at risk of pressure ulceration.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 10 studies with 11 publications (2261 participants analysed). Seven targeted their intervention at people at risk of ulceration and measured outcomes on these at risk people; two targeted those at risk and their family carers and measured outcomes on the at risk people cared for by their families; and one targeted lay carers only and measured outcomes on the at risk people they cared for. There were two main types of interventions: the provision of information on prevention of pressure ulcers, and the use of different types of education programmes. Provision of information on the prevention of pressure ulcers Three studies (237 participants) reported data for this comparison: two provided information directly to those at risk and their carers, and the third provided information to lay carers. As data could not be pooled we present individual study data. The evidence for primary outcomes is of very low certainty (downgraded twice for study limitations and twice for imprecision). We are uncertain whether the combined use of a self-instruction manual and one-to-one patient training and counselling versus a self-instruction manual alone reduces the proportion of at risk people developing a new PU (risk ratio (RR) 0.40, 95% confidence interval (CI) 0.14 to 1.18), or whether carer self-instruction and one-to-one counselling versus self-instruction alone reduces the proportion of at risk people developing a new PU (RR 2.05, 95% CI 0.19 to 21.70). We are uncertain whether the use of home-based training, compared with routine ward-based training, reduces the proportion of at risk people developing a new PU (RR 0.53, 95% CI 0.27 to 1.02). One study explored the secondary outcome patient knowledge of pressure ulcer prevention; however, as usable data were not provided, we were unable to carry out further analysis, and no effect estimate could be calculated. Educational programmes on the prevention of pressure ulcers Seven studies (2024 participants analysed) provided data for this comparison. In all studies the intervention was aimed at people at risk of ulceration. Risk of pressure ulceration One secondary report of an included study reported the primary outcome as time to PU development or occurrence and three studies and one secondary report of an included study reported this as the proportion of at risk people developing a new PU. One study reported the secondary outcome grade of PU and five studies and one secondary report of an included study reported on patient knowledge. There is low certainty evidence of there being no clear difference in the proportion of participants developing a new PU between use of a pressure ulcer prevention care bundle (PUPCB) and standard care: HR 0.58, 95% CI 0.25 to 1.33 (downgraded twice for imprecision). One secondary report of an included study explored whether individualised PU education and monthly structured telephone follow-up reduces the mean time to PU occurrence. Not all participants in this study developed a pressure ulcer, therefore the mean time to pressure ulcer occurrence could not be calculated from the data. We are uncertain whether the following three interventions reduce the proportion of at risk people developing a new PU as we assessed the certainty of evidence as very low: individualised PU education and monthly structured telephone follow-up (RR 0.55, 95% CI 0.23 to 1.30), education delivery (RR 3.57, 95% CI 0.78 to 16.38), (downgraded twice for risk of bias and twice for imprecision); and computerised feedback and one-to-one consultations (no clear data provided), (downgraded twice for risk of bias and once for indirectness). Grade of pressure ulcer There is low certainty evidence that use of a PU prevention care bundle may make no difference to the severity of new PU development when compared with standard care. Patient knowledge We are uncertain whether the following interventions improve patient knowledge: enhanced educational intervention and structured follow-up (mean difference (MD) 9.86, 95% CI 1.55 to 18.17); multi component motivational interviewing/self-management with a multi component education intervention (no clear data provided); Spinal Cord Injury Navigator programme (no clear data provided); individualised PU education and monthly structured telephone follow-up (no clear data provided); computerised feedback (no clear data provided), structured, patient-centric PU prevention education event (MD 30.15, 95% CI 23.56 to 36.74). We assessed the certainty of the evidence for this outcome as low or very low (downgraded for risk of bias, imprecision, or indirectness).

AUTHORS' CONCLUSIONS

We are uncertain whether educational interventions make any difference to the number of new PUs that develop, or to patient knowledge based on evidence from the 10 included studies, which we assessed as of low or very low certainty due to problems with risk of bias, serious imprecision and indirectness. The low certainty of evidence means that additional research is required to confirm these results.

Substantiating Clinical Effectiveness and Potential Barriers to the Widespread Implementation of Spinal Cord Injury Telerehabilitation: A Systematic Review and Qualitative Synthesis of Randomized Trials in the Recent Past Decade

Introduction: Telemedicine across many specialties in clinical practice has been established in the literature regarding technology platforms, privacy issues, cost, and clinical effectiveness. However, the lack of data in these areas applicable to spinal cord injury telerehabilitation (teleSCI) still exists. The gaps in these knowledge areas continue to hinder its widespread implementation and serve as pathways for focused efforts in teleSCI research. Objective: This systematic review aims to substantiate the clinical effectiveness and potential barriers to teleSCI implementation by verifying the statistical significance of various clinical outcomes from randomized trials published within the recent past decade. Methods: A qualitative synthesis of randomized studies, conducted across various regions, was systematically reviewed after identifying relevant records from database search engines. Applied filters in the search included publication dates (2010-2020), humans, full-text, and no language preference. The 13 studies were selected per Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram, and the risk of bias across studies was evaluated by using the Physiotherapy Evidence Database scale of quality assessment. Results: Quantitative outcome measurements demonstrated positive impact across studies: 79.1% (34/43) of all measurements were statistically significant for positive outcomes and 18.6% (8/43) yielded no effect but were significant. Primary outcomes addressed various spinal cord injury (SCI) management areas; 38.5% (5/13) of studies also assessed secondary outcomes. Interventional platforms were conventional technologies used in telemedicine. One study (7.7%) achieved data encryption; no studies presented cost-analysis data. Conclusion: The majority of studies demonstrated significant positive outcomes to validate teleSCI clinical effectiveness through conventional technology. These results further expand our understanding of teleSCI's impact and its demonstrated potential for improving SCI individuals' lives. However, heterogeneity of selected studies limits the conclusive recommendations to address potential barriers to its widespread implementation. Moreover, the development of new data is warranted to promote "buy-in" of widespread teleSCI implementation.

Behavioral Interventions Using Consumer Information Technology as Tools to Advance Health Equity

The digital divide related to consumer information technologies (CITs) has diminished, thus increasing the potential to use CITs to overcome barriers of access to health interventions as well as to deliver interventions situated in the context of daily lives. However, the evidence base regarding the use and impact of CIT-enabled interventions in health disparity populations lags behind that for the general population. Literature and case examples are summarized to demonstrate the use of mHealth, telehealth, and social media as behavioral intervention platforms in health disparity populations, identify challenges to achieving their use, describe strategies for overcoming the challenges, and recommend future directions. The evidence base is emerging. However, challenges in design, implementation, and evaluation must be addressed for the promise to be fulfilled. Future directions include (1) improved design methods, (2) enhanced research reporting, (3) advancement of multilevel interventions, (4) rigorous evaluation, (5) efforts to address privacy concerns, and (6) inclusive design and implementation decisions.

A Scoping Review of Self-Management Interventions Following Spinal Cord Injury

Objective: To conduct a scoping review to identify what components of self-management are embedded in self-management interventions for spinal cord injury (SCI). Methods: In accordance with the approach and stages outlined by Arksey and O'Malley (2005), a comprehensive literature search was conducted using five databases. Study characteristics were extracted from included articles, and intervention descriptions were coded using Practical Reviews in Self-Management Support (PRISMS) (Pearce et al, 2016), Barlow et al (2002), and Lorig and Holman's (2003) taxonomy. Results: A total of 112 studies were included representing 102 unique self-management programs. The majority of the programs took an individual approach (52.0%) as opposed to a group (27.4%) or mixed approach (17.6%). While most of the programs covered general information, some provided specific symptom management. Peers were the most common tutor delivering the program material. The most common Barlow components included symptom management (n = 44; 43.1%), information about condition/treatment (n = 34; 33.3%), and coping (n = 33; 32.4%). The most common PRISMS components were information about condition and management (n = 85; 83.3%), training/rehearsal for psychological strategies (n = 52; 51.0%), and lifestyle advice and support (n = 52; 51.0%). The most common Lorig components were taking action (n = 62; 60.8%), resource utilization (n = 57; 55.9%), and self-tailoring (n = 55; 53.9%). Conclusion: Applying self-management concepts to complex conditions such as SCI is only in the earliest stages of development. Despite having studied the topic from a broad perspective, this review reflects an ongoing program of research that links to an initiative to continue refining and testing self-management interventions in SCI.

Translating a spinal cord injury self-management intervention for online and telehealth delivery: A community-engaged research approach

Objective: To develop educational content and pilot test the use of tablet computers (iPads), online content management platform (iTunes U) and video conferencing (FaceTime) for delivery of a peer supported, spinal cord injury self-management intervention, using a community-engaged research approach. Design: Cross-sectional convenience sampled pilot study; evaluation using a combination of observation and questionnaires. Setting: Community-based. Participants: Individuals with SCI (n = 10) recruited from the community. Interventions: Participants engaged in a hands-on evaluation of the educational content and technology. Outcome Measures: Usability and acceptability of educational content and technology. Results: Participants were receptive and satisfied with the iPad and iTunes U platform and the video chat experience. Statements by our participants demonstrated a clear preference for interactive and multimedia platforms to promote engagement with educational materials. The use of FaceTime to facilitate contact between the participant and PN demonstrated satisfactory usability and acceptability. The hands-on evaluation process highlighted the need for consideration of connectivity for rural participants and assistive technology needs. Conclusion: Our community-engaged research approach and evaluation processes provided direct user feedback on the online and telehealth implementation of PHOENIX that will guide development of the remaining educational content, and testing of the intervention in a future feasibility trial.

Telemedicine and multiple sclerosis: A comprehensive literature review

INTRODUCTION

Patients with multiple sclerosis (pwMS) face barriers accessing specialty care for evaluation and treatment. Telemedicine, the practice of clinical care at a distance with the aid of technology, may be a potential bridge to close the access gap for pwMS separated by distance or disability. The objective of this review was to investigate the types of telemedicine being utilized and overall outcomes for pwMS and their providers.

METHODS

A Boolean search of the medical literature was conducted between January 2000 and January 31, 2018. PubMed, EMBASE, PsycINFO and the Cochrane databases, were used to identify all relevant citations. Two reviewers independently appraised the articles for meeting study criteria and for study quality using the CASP system. Financial costs of the telemedicine applications were assessed.

RESULTS

A total of 28 studies involving 3252 participants met criteria for inclusion. Telemedicine interventions were classified, and outcomes were assessed systematically by the following categories: general MS care; rehabilitation and exercise; and neuropsychology/mental health. Studies showed a range of outcomes with variable quality. Overall, remote clinical examinations, long-term telemedicine management interventions and telerehabilitation were shown to be beneficial, cost-effective and satisfactory for patients and providers.

DISCUSSION

Telemedicine is a viable platform for delivering specialty MS care. Remote neurological assessments and several forms of therapy have been shown to be technically feasible. Optimal implementation and barriers to the use of telemedicine in the current healthcare system should be explored.

Lifestyle intervention for adults with spinal cord injury: Results of the USC-RLANRC Pressure Ulcer Prevention Study

CONTEXT/OBJECTIVE

Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

DESIGN

A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

SETTING

Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

PARTICIPANTS

Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

INTERVENTIONS

The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

OUTCOME MEASURES

Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

RESULTS

Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

CONCLUSIONS

Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01999816.

Self-management interventions for skin care in people with a spinal cord injury: part 2-a systematic review of use of theory and quality of intervention reporting

STUDY DESIGN

Systematic review.

OBJECTIVES

To examine use of theory and quality of reporting in skin care self-management interventions for people with SCI.

SETTING

International.

METHODS

The Theory Coding Scheme (TCS) and the Template for Intervention Description and Replication (TIDieR) checklist were applied by two independent researchers to 17 interventions identified in a systematic review of self-management interventions for skin care in people with SCI.

RESULTS

Six (35%) of the 17 interventions reviewed were reported to have a theoretical basis. Theories used included three of the most commonly featured in health behavior research (the Health Belief Model, Social Cognitive Theory, and the Transtheoretical Model). In these six interventions, theory was used to design content but not to select participants or tailor strategies. None of the interventions were used to test theories in the SCI population, or to propose theoretical refinements. Reporting quality was found to vary by TIDieR item, with 6-100% of interventions including recommended information. Information on two intervention fidelity items was missing in 53 and 82% of descriptions.

CONCLUSIONS

Use of theory and reporting quality in SCI self-management research remains suboptimal, potentially slowing down advancements in this area of research. Rehabilitation researchers should direct their efforts toward improving these practices to help build a science of SCI self-management that is cumulative and reproducible by clinicians, scientists, and policy makers.

SPONSORSHIP

This work was funded through a postdoctoral fellowship awarded to the first author by the Rick Hansen Institute.

Self-management interventions for skin care in people with a spinal cord injury: part 1-a systematic review of intervention content and effectiveness

Study design

Systematic review.

Objectives

To review the content and effectiveness of skin care self-management interventions for people with SCI.

Setting

International.

Methods

We searched electronic bibliographic databases, trial registers, and relevant reference lists. Eligibility criteria for the reviews of intervention content and effectiveness were identical with the exception of study design. The review of intervention content included non-randomized and randomized controlled trials (RCTs). The review of effectiveness included RCTs. A Behavior Change Technique (BCT) taxonomy of 93 BCTs was used to code intervention content. Intervention effects on outcomes of interest are summarized descriptively. Effect sizes were calculated, and the Cochrane risk of bias tool applied.

Results

In all, 15 studies testing 17 interventions were included in the review of intervention content. Interventions in these studies included 28 BCTs. The most common were “instructions on how to perform behavior” (16 interventions), “credible source” (12 interventions), and “social support (unspecified)” (9 interventions). Ten RCTs were included in the review of intervention effectiveness and they measured knowledge, self-efficacy, and skills relating to skin care/pressure ulcer (PU) prevention, skin care behaviors, skin status (PU prevalence, severity, and time to PU), and health-care utilization for skin problems. Evidence to support intervention effects on these outcomes was limited, particularly for clinical outcomes. Risk of bias assessments was often inconclusive due to poor reporting.

Conclusions

There is potential to design SCI skin care interventions that include currently untested BCTs. Further research and better consistency in outcome measurements and reporting are required to synthesize evidence on effectiveness.

A Community Perspective on Bowel Management and Quality of Life after Spinal Cord Injury: The Influence of Autonomic Dysreflexia

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p < 0.001) and more severe AD (p = 0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Telehealth in Physical Medicine and Rehabilitation: A Narrative Review

Telehealth refers to health care interactions that leverage telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Technology advances and research have expanded use of telehealth in health care delivery. Physical medicine and rehabilitation providers may use telehealth to deliver care to populations with neurologic and musculoskeletal conditions, commonly treated in both acute care and outpatient settings. Patients with impaired mobility and those living in locations with reduced access to care may particularly benefit. Video-teleconferencing has been shown to be effective for management of burn patients during acute rehabilitation, including reduced health care use expenses and less disruptions to care. Telehealth can facilitate developing interprofessional care plans. Patients with neurologic conditions including stroke, spinal cord injury, traumatic brain injury, and amyotrophic lateral sclerosis may use telehealth to monitor symptoms and response to treatment. Telehealth also may facilitate occupational and physical therapy programs as well as improve weight management and skin care in patients with chronic conditions. Other applications include imaging review in sports medicine, symptom management and counseling in concussion, traumatic brain injury, and pain management programs. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage. The expansion of telehealth services is expected to grow and has potential to improve patient satisfaction by delivering high quality and value of care.

Does attendance in SCI education courses impact health outcomes in acute rehabilitation?

OBJECTIVE

Though education about secondary complications following spinal cord injury (SCI) is a component of many rehabilitation programs, there is little research on their success in promoting healthier outcomes. This study examined 1) whether greater education course attendance was associated with improved health outcomes and quality of life and 2) whether completion of bladder management and skin care courses was associated with decreased incidence of urinary tract infections (UTIs) and pressure ulcers (PUs).

DESIGN

Retrospective medical record review.

SETTING AND PARTICIPANTS

Patients (N = 106) in a Veterans Administration (VA) SCI rehabilitation program who completed at least one education class from August 2008 to September 2012.

METHODS AND OUTCOME MEASURES

Records were reviewed to determine the number of education courses completed and patients' responses to the Satisfaction with Life Survey (SWLS), the short form of the Craig Handicap and Assessment Reporting Technique (CHART-SF), and Short Form Health Survey (SF-8) at admission, discharge, and 90 days post-discharge. Records were reviewed to determine frequency of UTIs and PUs from admission to discharge and from discharge to 90-day follow-up.

RESULTS

Regression analyses revealed no association between number of classes and self-reported health and quality of life. Skin care class attendance was associated with a decreased number of PUs. Greater overall attendance at education courses was unexpectedly associated with a higher number of UTIs from admission to discharge.

CONCLUSION

Results of the study are mixed. Multiple factors appear to impact the success of education interventions. Future research is needed to clarify the best approach.

A feasibility pilot using telehealth videoconference monitoring of home-based NMES resistance training in persons with spinal cord injury

INTRODUCTION

The objective of the study was to investigate the feasibility and initial efficacy of telehealth communication in conjunction with surface neuromuscular electrical stimulation (NMES) resistance training (RT) to induce muscle hypertrophy.

MATERIALS AND METHODS

This was a home-based setting of within-subject control design of trained vs controlled limbs. Five men with chronic (>1 year postinjury) motor-complete spinal cord injury (SCI) participated in a twice-weekly telehealth videoconference program using home-based NMES-RT for 8 weeks. Stimulation was applied to the knee extensor muscle group of the trained leg, while the untrained leg served as a control. Participants received real-time feedback to ensure a proper setup of electrodes and stimulator to monitor subject safety throughout the entire training session. Magnetic resonance imaging was used to measure cross-sectional areas (CSAs) and intramuscular fat (IMF) of the whole thigh and individual muscle groups. Average two-way travel time, distance traveled in miles and total cost of gas per mile were calculated.

RESULTS

Participants had 100% compliance. Trained whole and absolute knee extensor muscle CSA increased by 13% (P=0.002) and 18% (P=0.0002), with no changes in the controlled limb. Absolute knee flexor and adductor CSAs increased by 3% (P=0.02) and 13% (P=0.0001), respectively. Absolute whole thigh and knee extensor IMF CSAs decreased significantly in the trained limb by 14% (P=0.01) and 36% (P=0.0005), respectively, with no changes in controlled limb.

DISCUSSION

The pilot work documented that using telehealth communication is a safe, feasible and potentially cost-reducing approach for monitoring home-based NMES-RT in persons with chronic SCI. All trained muscles showed detectable muscle hypertrophy with concomitant decrease in ectopic adipose tissue.

Evidence of Benefit of Telerehabitation After Orthopedic Surgery: A Systematic Review

BACKGROUND

In addition to traditional physiotherapy, studies based on telerehabilitation programs have published the results of effectiveness, validity, noninferiority, and important advantages in some neurological, cognitive, and musculoskeletal disorders, providing an opportunity to define new social policies and interventions.

OBJECTIVES

The aim of this systematic review is to investigate the effects of telerehabilitation after surgical procedures on orthopedic conditions as well as to describe how interventions are designed and to determine whether telerehabilitation is comparable with conventional methods of delivery. This systematic review summarizes the levels of evidence and grades of recommendation regarding telerehabilitation intervention (synchronous or asynchronous provided via the telerehabilitation medium, either in conjunction with, or in isolation of, other treatment interventions) after surgical procedures on orthopedic conditions.

METHODS

Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scores and grade of recommendation following the recommendation of the Oxford Centre for Evidence-Based Medicine.

RESULTS

We found 3 studies with PEDro scores between 6 and 8, which is considered as level 1 evidence (good; 20% [3/15]), 4 studies with a score of 5, which is considered as level 2 evidence (acceptable; 27% [4/15]), and the remaining 8 studies had scores of 4 or less, which is considered (poor; 53% [8/15]). A total of 1316 participants received telerehabilitation intervention in the selected studies, where knee and hip replacement were 75% of all the studies. Strong and moderate grades of evidence (grade of recommendation A-B) were found in knee and hip replacement interventions. Studies on the upper limb were 25% of the studies, but only 1 study presented a moderate grade of evidence (grade of recommendation B) and the rest were of poor methodological quality with weak evidence (grade of recommendation C).

CONCLUSIONS

Conclusive evidence on the efficacy of telerehabilitation for treatment after an orthopedic surgery, regardless of pathology, was not obtained. We found strong evidence in favor of telerehabilitation in patients following total knee and hip arthroplasty and limited evidence in the upper limb interventions (moderate and weak evidence). Future research needs to be more extensive and conclusive. To the best of the authors' knowledge, this is the first attempt at evaluating the quality of telerehabilitation intervention research after surgical procedures on orthopedic conditions in a systematic review. Clinical messages and future research recommendations are included in the review.

Viewing Telehealth Through the Lens of a Community Benefit Mission

INTRODUCTION

This article reviews the intersection of common objectives between telehealth initiatives launched by health systems and community health (specifically community benefit). Telehealth initiatives can benefit communities and play a potential role in improving population health. There is great opportunity to better integrate telehealth activities into community health strategies and community benefit reporting (for nonprofit hospitals) while building the case for telehealth service expansion.

METHODS

Through descriptive, hypothetical cases, we demonstrate the intersection of the triple aim, specifically improving population-level health, and three common objectives between telehealth and community benefit: (1) improving access to care, (2) enhancing community health, and (3) advancing medical or healthcare knowledge.

CONCLUSIONS

This article is intended to spur inspiration for possible telehealth and community health/community benefit connections.

Randomized Trial of a Peer-Led, Telephone-Based Empowerment Intervention for Persons With Chronic Spinal Cord Injury Improves Health Self-Management

OBJECTIVE

To evaluate the impact of "My Care My Call" (MCMC), a peer-led, telephone-based health self-management intervention in adults with chronic spinal cord injury (SCI).

DESIGN

Single-blinded randomized controlled trial.

SETTING

General community.

PARTICIPANTS

Convenience sample of adults with SCI (N=84; mean time post-SCI, 9.9y; mean age, 46y; 73.8% men; 44% with paraplegia; 58% white).

INTERVENTIONS

Trained peer health coaches applied the person-centered health self-management intervention with 42 experimental subjects over 6 months on a tapered call schedule. The 42 control subjects received usual care. Both groups received the MCMC Resource Guide.

MAIN OUTCOME MEASURES

Primary outcome-health self-management as measured by the Patient Activation Measure (PAM). Secondary outcomes-global ratings of service/resource use, health-related quality of life, and quality of primary care.

RESULTS

Intervention participants averaged 12 calls over 6 months (averaging 21.8min each), with distinct variation. At 6 months, intervention participants reported a significantly greater change in PAM scores (6mo: estimate, 7.029; 95% confidence interval, .1018-13.956; P=.0468) compared with controls, with a trend toward significance at 4 months. At 6 months, intervention participants reported a significantly greater decrease in social/role activity limitations (estimate, -.443; P=.0389), greater life satisfaction (estimate, 1.0091; P=.0522), greater services/resources awareness (estimate, 1.678; P=.0253), greater overall service use (estimate, 1.069; P=.0240), and a greater number of services used (estimate, 1.542; P=.0077). Subgroups most impacted by MCMC on PAM change scores included the following: high social support, white persons, men, 1 to 6 years postinjury, and tetraplegic.

CONCLUSIONS

This trial demonstrates that the MCMC peer-led, health self-management intervention achieved a positive impact on self-management to prevent secondary conditions in adults with SCI. These results warrant a larger, multisite trial of its efficacy and cost-effectiveness.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND

Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

INTRODUCTION

Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

MATERIALS AND METHODS

We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

RESULTS

Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

DISCUSSION

The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

CONCLUSIONS

CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Systematic review of behavioral and educational interventions to prevent pressure ulcers in adults with spinal cord injury

OBJECTIVE

To investigate the efficacy of behavioral or educational interventions in preventing pressure ulcers in community-dwelling adults with spinal cord injury (SCI).

DATA SOURCES

Cochrane, Clinical Trials, PubMed, and Web of Science were searched in June 2016. The search combined related terms for pressure ulcers, spinal cord injury, and behavioral intervention. Each database was searched from its inception with no restrictions on year of publication.

REVIEW METHODS

Inclusion criteria required that articles were (a) published in a peer-reviewed journal in English, (b) evaluated a behavioral or educational intervention for pressure ulcer prevention, (c) included community-dwelling adult participants aged 18 years and older with SCI, (d) measured pressure ulcer occurrence, recurrence, or skin breakdown as an outcome, and (e) had a minimum of 10 participants. All study designs were considered. Two reviewers independently screened titles and abstracts. Extracted information included study design, sample size, description of the intervention and control condition, pressure ulcer outcome measures, and corresponding results.

RESULTS

The search strategy yielded 444 unique articles of which five met inclusion criteria. Three were randomized trials and two were quasi-experimental designs. A total of 513 participants were represented. The method of pressure ulcer or skin breakdown measurement varied widely among studies. Results on pressure ulcer outcomes were null in all studies. Considerable methodological problems with recruitment, intervention fidelity, and participant adherence were reported.

CONCLUSIONS

At present, there is no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure ulcer occurrence in adults with SCI.

Differential Impact and Use of a Telehealth Intervention by Persons with MS or SCI

OBJECTIVE

The objective of this study was to compare outcomes and patterns of engaging with a telehealth intervention (CareCall) by adult wheelchair users with severe mobility limitations with a diagnosis of multiple sclerosis (MS) or spinal cord injury (SCI).

DESIGN

The design of this study is a secondary analysis from a pilot randomized controlled trial with 106 participants with SCI and 36 participants with MS.

RESULTS

General linear model results showed that an interaction between baseline depression score and study group significantly predicted reduced depression at 6 mos for subjects with both diagnoses (P = 0.01). For those with MS, CareCall increased participants' physical independence (P < 0.001). No statistically significant differences in skin integrity were found between study groups for subjects with either diagnosis. All participants were similarly satisfied with CareCall, although those with MS engaged in almost double the amount of calls per person than those with SCI (P = 0.005). Those with SCI missed more calls (P < 0.001) and required more extensive support from a nurse (P = 0.006) than those with MS.

CONCLUSION

An interactive telephone intervention was effective in reducing depression in adult wheelchair users with either MS or SCI, and in increasing health care access and physical independence for those with a diagnosis of MS. Future research should aim to enhance the efficacy of such an intervention for participants with SCI.

The delivery of specialist spinal cord injury services in Queensland and the potential for telehealth

Background

The Queensland Spinal Cord Injuries Service (QSCIS) is a statewide service in Brisbane at the Princess Alexandra Hospital (PAH). The QSCIS assists individuals with a spinal cord injury (SCI) through three services: the Spinal Injuries Unit (SIU), Transitional Rehabilitation Program (TRP) and the Spinal Outreach Team (SPOT). The aim of this study was to undertake a review of ambulatory services provided by the QSCIS (SIU and SPOT) to help identify where telehealth may potentially be useful.

Methods

Profiling of patients with SCI in Queensland was achieved using database records containing referral data. Services provided by SIU Outpatient Clinics and the SPOT during a 6-year period (January 2008 – December 2013), were analysed. Using postcodes, we estimated distances between place of residence and Brisbane. We compared the general population of SCI patients with patients managed through SIU Outpatient Clinics and the SPOT.

Results

During the 6-year period, 2073 patients were referred to the QSCIS (and living) at the time of the analysis. 74 % of all patients were male. The median age was 51y (IQR 39y-61y). About two-thirds of all patients lived within 200 km of Brisbane. 24 % of all patients registered with the QSCIS lived further than 200 km away from Brisbane.

7513 appointments were provided in the SIU outpatient clinic. 43,827 occasions of service were reported by the SPOT, including telephone consultations (66 %) and home visits (26 %). 72 outreach clinics were held in selected regional sites for up to 100 patients per year. 13 videoconference appointments reported.

90 % of all patients who attended the SIU outpatient clinic lived within 200 km of Brisbane. About two-thirds of patients who received a service from the SPOT lived within 200 km of Brisbane.

Conclusion

Since one third of all patients registered with the QSCIS live at least 200 km away from Brisbane; it appears that these patients may not be accessing the same services as Brisbane based patients. Telehealth models of care, which promote better engagement with local health service providers (such as general practitioners, nurse practitioners and allied health professionals) could improve equity of access and reduce the need for extensive travel.

Automated conversation system before pediatric primary care visits: a randomized trial

BACKGROUND AND OBJECTIVES

Interactive voice response systems integrated with electronic health records have the potential to improve primary care by engaging parents outside clinical settings via spoken language. The objective of this study was to determine whether use of an interactive voice response system, the Personal Health Partner (PHP), before routine health care maintenance visits could improve the quality of primary care visits and be well accepted by parents and clinicians.

METHODS

English-speaking parents of children aged 4 months to 11 years called PHP before routine visits and were randomly assigned to groups by the system at the time of the call. Parents' spoken responses were used to provide tailored counseling and support goal setting for the upcoming visit. Data were transferred to the electronic health records for review during visits. The study occurred in an urban hospital-based pediatric primary care center. Participants were called after the visit to assess (1) comprehensiveness of screening and counseling, (2) assessment of medications and their management, and (3) parent and clinician satisfaction.

RESULTS

PHP was able to identify and counsel in multiple areas. A total of 9.7% of parents responded to the mailed invitation. Intervention parents were more likely to report discussing important issues such as depression (42.6% vs 25.4%; P < .01) and prescription medication use (85.7% vs 72.6%; P = .04) and to report being better prepared for visits. One hundred percent of clinicians reported that PHP improved the quality of their care.

CONCLUSIONS

Systems like PHP have the potential to improve clinical screening, counseling, and medication management.

Relationship of perceived environmental barriers and disability in community-dwelling elderly in Taiwan--a population-based study

Background

To identify the relationship between perceived environmental barriers and disability in community-dwelling elderly.

Methods

Cross-sectional study in two community service centers in Tainan. We enrolled 200 community-dwelling residents, aged above 65 years, who had resided in the same community for at least 12 months. Basic activity of daily living (BADL) and instrumental activity of daily living (IADL) were assessed using the Hierarchy of Care Required (HCR). There were 59 participants in BADL disability and 109 in IADL disability. Perceived environmental barriers were assessed using the Craig Hospital Inventory of Environmental Factors (CHIEF). We used multinomial logistic regression to examine the relationship of perceived environmental barriers and disability.

Results

The presence of perceived environmental barriers was related to BADL disability (OR = 4.39, 95% CI = 1.01-19.11) and IADL disability (IADL with difficulty in 1–2 tasks: OR = 9.93, 95% CI = 3.22-30.56; IADL with difficulty in more than 2 tasks: OR = 8.40, 95% CI = 1.83-38.51). The presence of physically/structurally perceived environmental barriers was related to BADL disability (OR = 4.90, 95% CI = 1.01-23.86) and IADL disability (IADL with difficulty in 1–2 tasks: OR = 4.61, 95% CI = 1.27-16.76; IADL with difficulty in more than 2 tasks: OR = 17.05, 95% CI = 2.82-103.30).

Conclusions

Perceived environmental barriers are related to disability in community-dwelling elderly.