The Impact of Telemedicine on Greenhouse Gas Emissions at an Academic Health Science Center in Canada

Assessing the Carbon Footprint of Telemedicine: A Systematic Review

Background

Healthcare is responsible for 4% to 10% of carbon emissions worldwide, of which 22% is related to transport. Telemedicine emerged as a potential solution to reduce the footprint, for example, by reducing travel. However, a need to understand which variables to include in carbon footprint estimations in telemedicine limits our understanding of the beneficial impact telemedicine might have on our environment. This paper aims to systematically assess the reported carbon footprint and include variables assessed by the literature, comparing telemedicine with usual care.

Methods

The systematic review followed the PRISMA guidelines in PubMed, Medline, Embase and Scopus. A quality assessment was performed using a transparency checklist for carbon footprint calculators. Carbon emissions were evaluated based on four categories, including patient travel, and streamlined life cycle assessment (LCA) for assessing included variables relevant to telemedicine.

Results

We included 33 articles from 1117 records for analysis. The average transparency score was 38% (range 18%-68%). The median roundtrip travel distance for each patient was 131 km (interquartile range [IQR]: 60.8-351), or 25.6 kgCO2 (IQR: 10.6-105.6) emissions. There is high variance among included variables. Saved emissions are structurally underestimated by not including external factors such as a streamlined LCA.

Conclusions

Telemedicine aids in reducing emissions, with travel distance being the most significant contributor. Additionally, we recommend accounting for the LCA since it highlights important nuances. This review furthers the debate on assessing carbon footprint savings due to telemedicine.

The surgical outpatient clinic and the environment

Rising global temperatures will have a radical impact on the environment where global warming is associated with weather extremes such as thunderstorms and droughts which can affect the regional ecosystems. The healthcare sector is a major emitter of greenhouse gasses. Within healthcare, the outpatient clinic is responsible for a considerable sum of emissions. These can be organized under scopes 1, 2 and 3 as described in the Greenhouse Gas Protocol where scope 1 accounts for direct emissions from healthcare facilities, scope 2 is emissions from purchased electricity and scope 3 is indirect emissions including procurement and waste. Emissions and mitigation strategies from the surgical outpatient clinic are outlined under each scope of the Greenhouse Gas Protocol. These include using insulation materials, renovating or building new facilities, incorporating renewable energy sources and utilizing more efficient appliances. Telehealth and virtual clinics have been shown to be an effective method of delivering care while avoiding the combustion of fossil fuels to facilitate patient transport. In addition, virtual set-ups are cost effective and have not been proven to compromise patient safety when implemented correctly.

Reduction of Environmental Pollutants and Travel Burden Through an Academic Medical Center-based Electronic Consultation Program

Background: We evaluated the impact of electronic consultation (eConsult) in reducing the environmental pollutants associated with health care delivery. Methods: A retrospective analysis of the eConsult data between July 2018 and December 2022 was extracted from the electronic health record (Epic). Travel time and mileage from the patient home to the academic medical center (AMC) were calculated along with fuel expenditure and greenhouses gas savings. Projected savings through the end of the decade were forecast using a random walk model. Results: A total of 15,499 eConsults were submitted to AMC specialist providers from community primary care providers. Completed eConsults (n = 11,590) eliminated the need for a face-to-face visit with a specialist provider, eliminating mileage, fuel, time, and pollutants associated with face to face visits. In-state travel distance saved was 310,858 miles, travel time saved was 5,491 h, with an associated fuel reduction of 13,575 gallons and $56,893 savings. This reduced greenhouse gas emissions by 128 metric tons of carbon dioxide, 0.022 tons of nitrogen oxide, 0.005 tons of methane, and 0.001 tons of nitrous oxide. Out of state travel distance saved was 188,346 miles with 2,842 h reduced travel time, and associated fuel reduction of 8,225 gallons and of $34,118. Reduced greenhouse gas emissions were equivalent to 77 metric tons of carbon dioxide, 0.0132 tons of nitrogen oxide, 0.0033 tons of methane, and 0.0007 tons of nitrous oxide. Conclusion: This study indicates that medical care provided through telehealth modalities reduces the environmental impact of pollutants associated with face to face visits.

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic

OBJECTIVES

The Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions.

METHODS

We conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children's hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019-March 15, 2020) and during the COVID-19 pandemic (March 16, 2020-March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use.

RESULTS

There were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year.

CONCLUSIONS

Widespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Evaluating the Impact of Telehealth on Carbon Footprint During Three Phases of the Pandemic at a Rural Academic Medical Center

Background: Climate change is primarily driven by greenhouse gases, such as carbon dioxide (CO2). Telehealth visits have been found to mitigate carbon emissions by reducing patient and physician transport. Dartmouth Hitchcock Medical Center (DHMC) is the most rural academic medical center in the country, serving a population where the majority of patients reach the hospital by car. No large study or systematic review has evaluated the impact of telehealth visits on CO2 emissions (CO2e) across multiple specialties in a purely rural setting. Further, no sizable rurally focused study has compared CO2e avoided during the various stages of the pandemic. Methods: We extracted data for all outpatient telehealth visits at DHMC from three periods: prepandemic, early pandemic, and late pandemic. The extracted data included the pandemic stage of the virtual visit, the type of visit (video or telephone), the specialty, and the distance from the patient's home to DHMC. Results: The total CO2e avoided among all three pandemic stages analyzed in this study was 23,658,898 kg (n = 251,832). During period 1, the mean driving distance = 159.0 miles; CO2e avoided per encounter = 128.3 kg; period 2, mean distance = 84.85 miles; average CO2e avoided per encounter = 68.47 CO2e kg; and period 3, mean distance = 112.9 miles; average CO2e avoided per encounter = 91.08 kg. Conclusions: This data supported long distances to the medical center and large savings in CO2e avoided across multiple specialties that spanned all pandemic periods. Further, this level of averted emissions could translate to over $3M in saved fuel costs and the avoidance of six excess deaths. While discussions of the future of telehealth commonly focus on access, use cases, technology, costs, and satisfaction, the impact on carbon footprint is an additional important metric, particularly in largely rural regions.

Cost analysis of telemedicine use in paediatric nephrology-the LMIC perspective

BACKGROUND

The overall cost of managing chronic diseases is a significant barrier to accessing complete and timely healthcare, especially in rural and geographically isolated areas. This cost disparity becomes more pronounced in the case of children and more so in under-resourced regions of the world. In the era of COVID-19, as the need for physical distancing increased, there was a transition in approach to healthcare provision to telemedicine consultations. This study evaluates the cost saving using teleconsultations in a paediatric nephrology clinic.

METHODS

This prospective cohort study was conducted at AIIMS Jodhpur, a tertiary care centre in western Rajasthan from March 2021 to October 2022. All consecutive paediatric (29 days-18 years) patients attending telemedicine services for kidney-related illness were enrolled. Basic demographic details were collected. Cost analysis was done after 6 months, regarding perceived cost savings for the patient and family by using telehealth for follow-up during 6 months starting from enrolment.

RESULTS

A total of 112 patients were enrolled; 266 teleconsultations attended; 109 patients who could be followed up saved INR 457,900 during 6 months of follow-up. The average cost saving was INR - 1577/patient/visit. Patients saved 4.99% of the family income (median 2.16% (IQR 0.66-5.5)). The highest expenditure per visit was incurred for food and transport. The median distance from the residence to the clinic was 122.5 km (IQR 30-250). Over the 6-month study period, patients saved a travel distance of 83,274 km (743 km/patient).

CONCLUSIONS

The use of telemedicine as a follow-up method helps save significant costs and distances travelled by patients. A higher-resolution version of the Graphical abstract is available as Supplementary information.

Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review

The healthcare industry has a substantial impact on the environment through its use of resources, waste generation and pollution. To manage and reduce its impact, it is essential to measure the pressures of healthcare activities on the environment. However, research on factors that can support these measurement activities is unbalanced and scattered. In order to address this issue, a scoping review was conducted with the aims of (i) identifying and organizing factors that have been used to measure environmental impact in healthcare practice and (ii) analyzing the overview of impact factors in order to identify research gaps. The review identified 46 eligible articles publishing 360 impact factors from original research in PubMed and EBSCO databases. These factors related to a variety of healthcare settings, including mental healthcare, renal service, primary healthcare, hospitals and national healthcare. Environmental impacts of healthcare were characterized by a variety of factors based on three key dimensions: the healthcare setting involved, the measurement component or scope, and the type of environmental pressure. The Healthcare Environmental Impact Factor (HEIF) scheme resulting from this study can be used as a tool for selecting measurable indicators to be applied in quality management and as a starting point for further research. Future studies could focus on standardizing impact factors to allow for cross-organization comparisons and on expanding the HEIF scheme by addressing gaps.

Environmental Impact of Ambulatory Telehealth Use by a Statewide University Health System During COVID-19

Objective: Several studies before the COVID-19 pandemic documented the positive impact of telehealth on patients' travel distance, time, out-of-pocket costs, and greenhouse gas emissions. The objective of this study was to calculate these outcomes following the increased use of ambulatory telehealth services within five large University of California (UC) health care systems during the COVID-19 pandemic. Methods: We analyzed retrospective ambulatory telehealth data from the five UC health care systems between March 1, 2020, and February 28, 2022. Travel distances and time saved were calculated using the round-trip distance a patient would have traveled for an in-person visit, while cost savings were calculated using Internal Revenue Services' (IRS) 2022 standard mileage reimbursement rates. In addition, we estimated the injuries and fatalities avoided using the national motor vehicle crash data. Greenhouse gas emissions were estimated using the 2021 national average vehicle emission rates. Results: More than 3 million (n = 3,043,369) ambulatory telehealth encounters were included in the study. The total round-trip distance, travel time, and travel cost saved from these encounters were 53,664,391 miles, 1,788,813 h, and $33,540,244, respectively. These translated to 17.6 miles, 35.3 min, and $11.02 per encounter. By using telehealth, 42.4 crash-related injuries and 0.7 fatalities were avoided. The use of telehealth for ambulatory services during this time eliminated 21465.8 metric tons of carbon dioxide, 14.1 metric tons of total hydrocarbons, 212.3 metric tons of exhaust carbon monoxide, and 9.3 metric tons of exhaust nitrogen oxide emissions. Conclusions: Telehealth use for ambulatory services in a statewide academic Health System during COVID-19 had a positive impact on patient travel distance, time and costs, injuries and fatalities in motor vehicle accidents, and greenhouse gas emissions. These significant advantages of telehealth should be considered when planning future health services.

How Can We Make Hand Surgery Carbon Neutral?

BACKGROUND

Climate change is a major public health threat worldwide. Operating theaters are responsible for extensive waste production due to the resource-intensive nature of surgery, including hand surgery.

METHODS

An online literature search was performed to ascertain the approaches that surgeons may undertake to positively impact the environment.

RESULTS

Surgeons can make hand surgery more carbon neutral through various measures that have been categorized as pre-, intra-, and postoperative interventions. With all changes, the aims are to minimize waste and costs while optimizing patient outcomes.

CONCLUSIONS

Administrative obstacles to implementing pro-climate hospital changes may be overcome by also considering likely cost benefits with many environmentally friendly measures. New measures in hand surgery should consider patient safety, clinical efficacy, cost effectiveness, and the environmental impact.

Inclusion of Environmental Spillovers in Applied Economic Evaluations of Healthcare Products

OBJECTIVES

Climate change and environmental factors have an impact on human health and the ecosystem. The healthcare sector is responsible for substantial environmental pollution. Most healthcare systems rely on economic evaluation to select efficient alternatives. Nevertheless, environmental spillovers of healthcare treatments are rarely considered whether it is from a cost or a health perspective. The objective of this article is to identify economic evaluations of healthcare products and guidelines that have included any environmental dimensions.

METHODS

Electronic searches of 3 literature databases (PubMed, Scopus, and EMBASE) and official health agencies guidelines were conducted. Documents were considered eligible if they assessed the environmental spillovers within the economic evaluation of a healthcare product or provided any recommendations on the inclusion of environmental spillovers in the health technology assessment process.

RESULTS

From the 3878 records identified, 62 documents were deemed eligible and 18 were published in 2021 and 2022. The environmental spillovers considered were carbon dioxide (CO₂) emissions, water or energy consumption, and waste disposal. The environmental spillovers were mainly assessed using the lifecycle assessment (LCA) approach while the economic analysis was mostly limited to costs. Only 9 documents, including the guidelines of 2 health agencies presented theoretical and practical ways to include environmental spillovers into the decision-making process.

CONCLUSIONS

There is a clear lack of methods on whether environmental spillovers should be included in health economic evaluation and how this should be done. If healthcare systems want to reduce their environment footprint, the development of methodology which integrates environmental dimensions in health technology assessment will be key.

The role of virtual consulting in developing environmentally sustainable healthcare: a systematic literature review (Preprint)

BACKGROUND

Health systems globally need to rapidly set and achieve targets for reaching net zero carbon emissions. Virtual consulting (including video- and telephone-based consulting) is regarded as one means by which this might be achieved, largely through reduced patient travel. Little is currently known about the ways in which forms of virtual consulting might contribute to the net zero agenda or how countries may develop and implement programs at scale that can support increased environmental sustainability.

OBJECTIVE

In this paper, we asked, What is the impact of virtual consulting on environmental sustainability in health care? and What can we learn from current evaluations that can inform future reductions in carbon emissions?

METHODS

We conducted a systematic review of published literature according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. We searched the MEDLINE, PubMed, and Scopus databases using key terms relating to "carbon footprint," "environmental impact," "telemedicine," and "remote consulting," using citation tracking to identify additional articles. The articles were screened, and full texts that met the inclusion criteria were obtained. Data on the approach to carbon footprinting reported reductions in emissions, and the opportunities and challenges associated with the environmental sustainability of virtual consultations were extracted into a spreadsheet, analyzed thematically, and theorized using the Planning and Evaluating Remote Consultation Services framework to consider the various interacting influences, including environmental sustainability, that shape the adoption of virtual consulting services.

RESULTS

A total of 1672 papers were identified. After removing duplicates and screening for eligibility, 23 papers that focused on a range of virtual consulting equipment and platforms across different clinical conditions and services were included. The focus on the environmental sustainability potential of virtual consulting was unanimously reported through carbon savings achieved by a reduction in travel related to face-to-face appointments. The shortlisted papers used a range of methods and assumptions to determine carbon savings, reporting these using different units and across varied sample sizes. This limited the potential for comparison. Despite methodological inconsistencies, all papers concluded that virtual consulting significantly reduced carbon emissions. However, there was limited consideration of wider factors (eg, patient suitability, clinical indication, and organizational infrastructure) influencing the adoption, use, and spread of virtual consultations and the carbon footprint of the entire clinical pathway in which the virtual consultation was provided (eg, risk of missed diagnoses from virtual consultations that result in the need for subsequent in-person consultations or admissions).

CONCLUSIONS

There is overwhelming evidence that virtual consulting can reduce health care carbon emissions, largely through reducing travel related to in-person appointments. However, the current evidence fails to look at system factors associated with implementing virtual health care delivery and wider research into carbon emissions across the entire clinical pathway.

The environmental impact of health care for musculoskeletal conditions: A scoping review

BACKGROUND

Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions.

METHODS

We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed.

RESULTS

Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1).

CONCLUSION

Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.

Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study

Objective

The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting.

Method

2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates.

Results

Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote.

Conclusion

Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

Digital health for climate change mitigation and response: a scoping review

OBJECTIVE

Climate change poses a major threat to the operation of global health systems, triggering large scale health events, and disrupting normal system operation. Digital health may have a role in the management of such challenges and in greenhouse gas emission reduction. This scoping review explores recent work on digital health responses and mitigation approaches to climate change.

MATERIALS AND METHODS

We searched Medline up to February 11, 2022, using terms for digital health and climate change. Included articles were categorized into 3 application domains (mitigation, infectious disease, or environmental health risk management), and 6 technical tasks (data sensing, monitoring, electronic data capture, modeling, decision support, and communication). The review was PRISMA-ScR compliant.

RESULTS

The 142 included publications reported a wide variety of research designs. Publication numbers have grown substantially in recent years, but few come from low- and middle-income countries. Digital health has the potential to reduce health system greenhouse gas emissions, for example by shifting to virtual services. It can assist in managing changing patterns of infectious diseases as well as environmental health events by timely detection, reducing exposure to risk factors, and facilitating the delivery of care to under-resourced areas.

DISCUSSION

While digital health has real potential to help in managing climate change, research remains preliminary with little real-world evaluation.

CONCLUSION

Significant acceleration in the quality and quantity of digital health climate change research is urgently needed, given the enormity of the global challenge.

Association of Virtual Care Expansion With Environmental Sustainability and Reduced Patient Costs During the COVID-19 Pandemic in Ontario, Canada

IMPORTANCE

There is a growing focus on environmental sustainability in health care.

OBJECTIVE

To estimate the environmental and patient-level financial benefits associated with the widespread adoption of virtual care during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study obtained data from linked administrative databases in the universal health care system of Ontario, Canada, from March 2020 to December 2021. Participants included all people with a physician claim for at least 1 episode of virtual care.

EXPOSURES

Patients were stratified by age, socioeconomic status quintiles, Charlson Comorbidity Index, and area of residence (rural or urban).

MAIN OUTCOMES AND MEASURES

The primary outcomes were total travel distance and estimated travel-related carbon dioxide emissions avoided owing to virtual care visits. Different model assumptions were used to account for electric and hybrid vehicles and public transit use. The secondary outcomes were estimated patient costs (gasoline, parking, or public transit expenses) avoided.

RESULTS

During the 22-month study period, 10 146 843 patients (mean [SD] age, 44.1 [23.1] years; 5 536 611 women [54.6%]) had 63 758 914 physician virtual care visits. These visits were associated with avoidance of 3.2 billion km of travel distance and between 545 and 658 million kg of carbon dioxide emissions. Patients avoided an estimated total of $569 to $733 million (Canadian [US $465-$599 million]) in parking, public transit, and gasoline costs. Carbon dioxide emission avoidance and patient cost savings were more apparent in patients living in rural areas, those with higher comorbidity, and those who were older than 65 years.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that virtual care was associated with a large amount of carbon dioxide emissions avoided owing to reduced patient travel and with millions of dollars saved in parking, gasoline, or public transit costs. These benefits are likely to continue as virtual care is maintained as part of the health care system.

A Transparency Checklist for Carbon Footprint Calculations Applied within a Systematic Review of Virtual Care Interventions

Increasing concerns about climate change imply that decisions on the digitization of healthcare should consider evidence about its carbon footprint (CF). This study aims to develop a transparency catalogue for reporting CF calculations, to compare results, and to assess the transparency (reporting quality) of the current evidence of virtual care (VC) intervention. We developed a checklist of transparency criteria based on the consolidation of three established standards/norms for CF calculation. We conducted a systematic review of primary studies written in English or German on the CF of VC interventions to check applicability. Based on our checklist, we extracted methodological information. We compared the results and calculated a transparency score. The checklist comprises 22 items in the aim, scope, data and analysis categories. Twenty-three studies out of 1466 records were included, mostly addressing telemedicine. The mean transparency score was 38% (minimum 14%, maximum 68%). On average, 148 kg carbon dioxide equivalents per patient were saved. Digitization may have co-benefits, improving care and reducing the healthcare CF. However, the evidence for this is weak, and CF reports are heterogeneous. Our transparency checklist may serve as a reference for developing a standard to assess the CF of virtual and other healthcare and public health services.

Greenhouse Gas Emission Savings in Relation to Telemedicine and Associated Patient Benefits: A Systematic Review

Introduction: Telemedicine is a rapidly expanding service in the digitization of health care systems. Recently emphasis has been placed on the decarbonization of health care systems with National and World Health Organization initiatives aimed at carbon neutrality toward the mid-21st century. This study investigates greenhouse gas emissions related to telemedicine, its potential role in achieving carbon neutrality and its role in determining policy. We further investigate patient benefits related to telemedicine. Methods: A systematic review was conducted of the PubMed, Medline, EMBASE, EMCARE, CINAHL, and HMIC databases. Eligibility of studies was determined by predefined criteria. Results: A total of 31 studies were identified totaling over 57,000 patients. Carbon savings ranged from 0.69 kg CO2e (carbon dioxide equivalent) to 893 kg CO2e per encounter. Distances saved also ranged from 6.1 to 3,386 km. Further analysis of 18 included studies was conducted for cost savings that ranged from €1.73 in fuel costs to over U.S. $900 in travel related expenses. Similarly, 15 included studies were analyzed for time savings, which ranged from 38 min to 24 h. Conclusions: There are substantial carbon savings to be made with telemedicine systems. Furthermore, there are substantial benefits to patients in terms of both time savings and cost savings. Rural and isolated communities or patients needing tertiary or quaternary care may be a particular cohort that might benefit disproportionally from telemedicine and is an area where the largest per capita emission savings can potentially be made.

A Study on Online Intervention for Early Childhood Eating Disorders during COVID-19

Eating disorders are among the most common clinical manifestations in children, and they are frequently connected with maternal psychopathological risk, internalizing/externalizing problems in children, and poor quality of mother–child feeding exchanges. During the COVID-19 lockdown, in person assessment and intervention were impeded due to the indications of maintaining interpersonal distancing and by limits to travel. Therefore, web-based methods were adopted to meet patients’ needs. In this study N = 278 participants completed the SCL-90/R and the CBCL to examine the psychopathological symptoms of mothers and children (age of the children = 24 months); moreover, the dyads were video-recorded during feeding and followed an online video-feedback based intervention. Maternal emotional state, interactive conflict, food refusal in children, and dyadic affective state all improved considerably, as did offspring internalizing/externalizing problems and mothers’ depression, anxiety, and obsession–compulsion symptoms. This study showed that video-feedback web-based intervention might be employed successfully to yield considerable beneficial effects.

Life Cycle Greenhouse Gas Emissions of Gastrointestinal Biopsies in a Surgical Pathology Laboratory

OBJECTIVES

Given adverse health effects of climate change and contributions of the US health care sector to greenhouse gas (GHG) emissions, environmentally sustainable delivery of care is needed. We applied life cycle assessment to quantify GHGs associated with processing a gastrointestinal biopsy in order to identify emissions hotspots and guide mitigation strategies.

METHODS

The biopsy process at a large academic pathology laboratory was grouped into steps. Each supply and reagent was catalogued and postuse treatment noted. Energy consumption was estimated for capital equipment. Two common scenarios were considered: 1 case with 1 specimen jar (scenario 1) and 1 case with 3 specimen jars (scenario 2).

RESULTS

Scenario 1 generated 0.29 kg of carbon dioxide equivalents (kg CO2e), whereas scenario 2 resulted in 0.79 kg CO2e-equivalent to 0.7 and 2.0 miles driven, respectively. The largest proportion of GHGs (36%) in either scenario came from the tissue processor step. The second largest contributor (19%) was case accessioning, mostly attributable to production of single-use disposable jars.

CONCLUSIONS

Applied to more than 20 million biopsies performed in the US annually, emissions from biopsy processing is equivalent to yearly GHG emissions from 1,200 passenger cars. Mitigation strategies may include modification of surveillance guidelines to include the number of specimen jars.

Positive environmental impact of remote teleconsultation in urology during the COVID-19 pandemic in a highly populated area

Introduction

Greenhouse gas (GHG) emissions are a serious environmental issue. The healthcare sector is an important emitter of GHGs. Our aim was to assess the environmental cost of teleconsultations in urology compared to face-to-face consultations.

Materials and methods

Prospective study of all patients who had a remote teleconsultation over a 2-week period during COVID-19 pandemic. Main outcome was the reduction in CO₂e emissions related to teleconsultation compared to face-to-face consultation and was calculated as: total teleconsultation CO₂e emissions–total face-to-face consultation CO₂e emissions. Secondary outcome measures were the reduction in travel distance and travel time related to teleconsultation.

Results

Eighty patients were included. Face-to-face consultations would have resulted in 6699 km (4162 miles) of travel (83.7 km (52 miles) per patient). Cars were the usual means of transport. CO₂e avoided due to lack of travel was calculated at 1.1 tonnes. Teleconsultation was responsible for 1.1 kg CO₂e while face-to-face consultation emitted 0.5 kg of CO₂e. Overall, the total reduction in GHGs with teleconsultation was 1141 kg CO₂e, representing a 99% decrease in emissions. Total savings on transport were 974 € and savings on travel time were 112 h (1.4 h/patient).

Conclusions

Teleconsultation reduces the environmental impact of face-to-face consultations. The use of teleconsultation in our urology departments resulted in the avoidance of more than 6000 km of travel, equivalent to a reduction of 1.1 tonnes of CO₂e. Teleconsultation should be considered for specific indications as the healthcare system attempts to become greener.

Level of evidence

3.

Medical conferences in the era of environmental conscientiousness and a global health crisis: The carbon footprint of presenter flights to pre-COVID pediatric urology conferences and a consideration of future options

INTRODUCTION

Medical conferences are integral to academic medicine, with academic posters being a well-established medium for presenting research. However, conferences carry an ecological footprint due to greenhouse gas emissions. Furthermore, traditional conference formats have recently not been possible due to the COVID-19 pandemic. Herein we examine the carbon footprint associated with travel by presenting delegates to the Fall SPU conferences from 2013 to 2019, and the 2015 ESPU conference.

METHODS

Online programs for the targeted SPU Fall meetings and the 2015 ESPU Annual Meeting were retrospectively reviewed. Variables collected included meeting location and presenter home base. Distance traveled by the presenter, and likely CO₂e of this return trip were estimated using online calculators. Analysis was performed using the Kruskal-Wallis-H test with pairwise comparisons to detect differences in round trip distances and CO₂e between meeting locations.

RESULTS

Six Fall SPU conferences and one ESPU conference were reviewed. The majority of presenters were from the region (North America and Europe, respectively), for both SPU and ESPU. The median round trip distance was 2596.34 miles (IQR 1420.96-4438.30), and the median CO₂e 0.61 metric tons (IQR 0.36-1.02). We found that the distances traveled to conferences in the Western USA and Europe were slightly further than those to conferences in Central Canada and the Southern US. The difference in CO₂e between these locations did not achieve statistical significance.

CONCLUSION

Presenter travel to and from pediatric urological conferences generates an important carbon footprint and may not be possible in the medium-term future due to a global pandemic. We should explore strategies to allow meetings and knowledge exchange to continue whilst reducing the need for travel and the ecological burden of conferences.

LEVEL OF EVIDENCE

Level III: Most comparative level of evidence.

Why telehealth does not always save money for the health system

Purpose

This study aims to determine elements of telehealth that have the potential to increase costs for the health system in the short to medium term.

Design/methodology/approach

A search of PubMed, EMBASE and Scopus databases was performed in May 2018 using broad terms for telehealth and economics. Articles were included if they identified and explained reasons for an increase in cost for telehealth services. Studies were categorised by economic analysis type for data extraction and descriptive synthesis.

Findings

Fourteen studies met inclusion criteria and were included in the review. These studies identified that increased health system costs were due to implementation costs (e.g. for equipment, software or staff training), increased use of other healthcare services (e.g. pharmaceutical services) and ongoing service costs (including staff salaries) resulting from telehealth being additive to traditional service (e.g. increased frequency of contact).

Originality/value

Telehealth is often assumed to be a cost-effective method of delivering healthcare, even to the point where direct cost savings are expected by decision makers as a result of implementation. However, this investigation suggests it does not routinely reduce costs for the health system and can actually increase costs at both implementation and ongoing service delivery stages. Health services considering implementing telehealth should be motivated by benefits other than cost reduction such as improved accessibility, greater patient centricity and societal cost–benefit.

Does telemedicine reduce the carbon footprint of healthcare? A systematic review

In the rapidly progressing field of telemedicine, there is a multitude of evidence assessing the effectiveness and financial costs of telemedicine projects; however, there is very little assessing the environmental impact despite the increasing threat of the climate emergency. This report provides a systematic review of the evidence on the carbon footprint of telemedicine. The identified papers unanimously report that telemedicine does reduce the carbon footprint of healthcare, primarily by reduction in transport-associated emissions. The carbon footprint savings range between 0.70-372 kg CO₂e per consultation. However, these values are highly context specific. The carbon emissions produced from the use of the telemedicine systems themselves were found to be very low in comparison to emissions saved from travel reductions. This could have wide implications in reducing the carbon footprint of healthcare services globally. In order for telemedicine services to be successfully implemented, further research is necessary to determine context-specific considerations and potential rebound effects.

Systematic Review of Telehealth Cost Minimization for Patients and Health Systems in Otolaryngology

OBJECTIVE/HYPOTHESIS

The COVID-19 pandemic has resulted in telehealth becoming commonplace in many health care fields. Telehealth benefits include improving access, decreasing costs, and elevating patient's experience. A review of cost minimization (CM) analyses was performed in order to explore scientific studies associated with integrating tele-otolaryngology in clinical practice. Our primary objective was to evaluate published literature for cost related to the implementation of telemedicine across otolaryngology, and to determine CM when compared to in-person visits.

STUDY DESIGN

Systematic Literature Review.

METHODS

We performed a systematic review using PubMed, EMBASE, and Cochrane in May 2020, to identify studies with a cost analysis of tele-otolaryngology care. Inclusion criteria focused on articles citing CM data from telehealth services. Literature quality was assessed using the MINORS scoring system.

RESULTS

From 380 original articles screened only nine evaluated cost in otolaryngology. CM in the US ranged from $68 to $900 per visit. Cost was evaluated in general otolaryngology, sleep medicine, otology, and head and neck cancer surgery, the latter had the most benefit. The most common types of telehealth visits were routine follow-up and screening. Data were insufficient for meta-analysis.

CONCLUSIONS

Telemedicine has been trialed across various otolaryngology subspecialties; its incorporation is projected to have a meaningful impact on access to specialty care. This research suggests that the delivery of virtual care reduces cost with the potential of increasing net revenue across multiple otolaryngology subspecialties. Further studies are needed to better discern the entirety of cost savings and the best settings for integration.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1741-1748, 2021.

Telemedicine and Smart Working: Recommendations of the European Association of Urology

CONTEXT

Telemedicine provides remote clinical support using technological tools. It may facilitate health care delivery while reducing unnecessary visits to the clinic. The coronavirus disease 2019 (COVID-19) outbreak has caused an abrupt change in our daily urological practice, converting many of us to be reliant on telehealth.

OBJECTIVE

To provide practical recommendations for effective use of technological tools in telemedicine.

EVIDENCE ACQUISITION

A Medline-based and gray literature search was conducted through April 2020. We selected the most relevant articles related to "telemedicine" and "smart working" that could provide important information.

EVIDENCE SYNTHESIS

Telemedicine refers to the use of electronic information and telecommunications tools to provide remote clinical health care support. Smart working is a model of work that uses new or existing technologies to improve performance. Telemedicine is becoming a useful invaluable tool during and even beyond the COVID-19 pandemic. It is time for us to formalize the place of telemedicine in routine urological practice, and it is our responsibility to adapt and learn about all the tools and possible strategies for their optimal implementation during the pandemic to ensure that the quality of care received by patients and the outcomes of patients and their families are of the highest standard.

CONCLUSIONS

Telemedicine facilitates specialized urological clinical support at a distance, solves problems of limitations in mobility, reduces unnecessary visits to clinics, and is useful for reducing the risk of viral transmission in the current COVID-19 outbreak. Furthermore, both personal and societal considerations may favor continued use of telemedicine, even beyond the COVID-19 pandemic.

PATIENT SUMMARY

Telemedicine in urology offers specialized remote clinical support to patients, similar to face-to-face visits. It is very useful for reducing unnecessary visits to the clinic, as well as reducing the risk of contagion in the current coronavirus disease 2019 (COVID-19) pandemic.

Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations

Introduction

Telemedicine provides remote clinical support through technology tools. It can facilitate medical care delivery while reducing unnecessary office visits. The COVID-19 outbreak has caused an abrupt change in our daily urological practice, where teleconsultations play a crucial role.

Objective

To provide practical recommendations for the effective use of technological tools in telemedicine.

Materials and methods

A literature search was conducted on Medline until April 2020. We selected the most relevant articles related to “telemedicine” and “smart working” that could provide valuable information.

Results

Telemedicine refers to the use of electronic information and telecommunication tools to provide remote clinical health care support. Smart working is a working approach that uses new or existing technologies to improve performance. Telemedicine is becoming a useful and fundamental tool during the COVID-19 pandemic and will be even more in the future. It is time for us to officially give telemedicine the place it deserves in clinical practice, and it is our responsibility to adapt and familiarize with all the tools and possible strategies for its optimal implementation. We must guarantee that the quality of care received by patients and perceived by them and their families is of the highest standard.

Conclusions

Telemedicine facilitates remote specialized urological clinical support and solves problems caused by limited patient mobility or transfer, reduces unnecessary visits to clinics and is useful to reduce the risk of COVID-19 viral transmission.

Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations

Introducción

La telemedicina ofrece un soporte clínico remoto utilizando herramientas tecnológicas. Puede facilitar la atención médica al tiempo que reduce las visitas innecesarias a la consulta. La pandemia COVID-19 ha provocado un cambio brusco en nuestra práctica urológica diaria convirtiéndose en algo muy necesario el acto de la teleconsulta.

Objetivo

Proporcionar recomendaciones prácticas para el uso efectivo de herramientas tecnológicas en telemedicina.

Materiales y métodos

Se realizó una búsqueda en la literatura en la plataforma Medline hasta abril de 2020; seleccionamos los artículos más relevantes relacionados con «telemedicina» y «trabajo inteligente» que podrían proporcionar información útil.

Resultados

La telemedicina se refiere al uso de la información electrónica y a las herramientas de telecomunicaciones para proporcionar apoyo clínico remoto a la atención médica. El trabajo inteligente es un modelo de trabajo que utiliza tecnologías nuevas o existentes para mejorar el rendimiento. La telemedicina se está convirtiendo en una herramienta útil y necesaria durante la pandemia COVID-19 e incluso más allá de la misma. Es hora de que formalicemos y demos el lugar que se merece a la telemedicina en nuestra práctica clínica y es nuestra responsabilidad adaptar y conocer todas las herramientas y posibles estrategias para su implementación de una manera óptima, garantizar una atención de calidad a los pacientes y que dicha atención sea percibida por pacientes y familiares como de alto nivel.

Conclusiones

La telemedicina facilita la atención clínica urológica especializada a distancia y resuelve problemas como las limitaciones en la movilidad o el traslado de los pacientes, reduce las visitas innecesarias a las clínicas y es útil para reducir el riesgo de transmisión viral de la COVID-19.

Environmental sustainability in anaesthesia and critical care

The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the 'state of the art' environmental sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. 'cradle to grave' analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.

Why be sustainable? The Australian and New Zealand College of Anaesthetists Professional Document PS64: Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice and its accompanying background paper

Healthcare’s environmental sustainability is increasingly an area of research and advocacy focus. The Australian and New Zealand College of Anaesthetists (ANZCA) has produced a professional document, PS64, Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, and a background paper, PS64 BP. The purpose of the statement is to affirm ANZCA’s commitment to environmental sustainability and support anaesthetists in promoting environmentally sustainable work practices. This article presents the main features of PS64 and its background paper, and the associated supporting evidence. The healthcare sector is highly interconnected with activities that emit pollution to air, water and soils, considerably adding to humanity’s collective ecological footprint. As anaesthetists, we are uniquely high-carbon doctors due to our work anaesthetising with greenhouse gases (particularly desflurane and nitrous oxide) and our exposure and contribution to large amounts of resource and energy use and waste generation in operating theatres. Discussion is made of the improving research base of anaesthetic life-cycle assessments—that is, cradle-to-grave studies of how much energy, water and so on a product or process requires throughout its entire life. Thereafter, reducing, reusing and recycling as well as water use are examined. Ongoing research efforts within environmentally sustainable anaesthesia are highlighted. Environmentally sustainable anaesthesia requires scholarship, health advocacy, leadership, communication and collaboration. The focus is placed on practical initiatives within PS64 and the background paper that can be achieved by all anaesthetists striving towards more sustainable healthcare practices that reduce waste, reap financial benefits and improve health.

ACCESS to Better Health and Clear Skies: Telemedicine and Greenhouse Gas Reduction

Introduction: This study estimates the reduction in greenhouse gas (GHG) emissions resulting from 2,020 neuro-emergent telemedicine consultations. We then estimate potential GHG reduction if the program was expanded nationwide. Materials and Methods: Travel distances in miles were calculated for each avoided patient transfer using hospital location data and ArcGIS^® tools. Potential GHG reductions from program expansion were calculated based on state and national stroke Diagnosis-Related Groups (DRGs). Along with average flight distance from a rural hospital to closest level one trauma center. Results: Participation in the Access to Critical Cerebral Emergent Support Services (ACCESS) from May 2015 to July 2017 resulted in 2,020 consultations. Of these consultations, there was a 70% (1,414) reduction in patient transfers. Emission reduction totaled 618,772 kg of carbon dioxide equivalents (CO₂e) (618.77 metric tons) or 0.306 metric tons of CO₂e per patient. Expanding the program across New Mexico and similar U.S. areas resulted in potential reductions of 4,307 (IQR 3,386-5,274) and 213,279 (IQR 169,320-263,570) metric tons of CO₂e. Conclusion: Transport accounts for 26% of global CO₂ emissions and is one of the few industrial sectors where emissions are still growing. What makes this study more impactful is that aviation's emissions are not part of the Kyoto Protocol and little is being done in this sector. GHG reduction was not the main intention of the ACCESS program, but it has shown to be a significant by-product.

Towards an ethics for telehealth

Over the last two decades, a public rationale for the implementation of telehealth has emerged at the interplay of specialised literature and political orientations. Despite the lack of consistent findings on the magnitude of its benefits, telehealth is nowadays presented as a worthy solution both for patients and healthcare institutions. Far from denying the potential advantages of telehealth, the main objective of this work is to provide a critical assessment on the spread of the remote services as a vector of positive transformation of contemporary health systems. For pursuing this objective, the EU agenda for the promotion of telehealth will be retraced, and the main evidences alleged to sustain the implementation of remote care services will be assessed. Furthermore, it will be evaluated the attempt made by the European Commission to establish an ethical framework for guiding the use of telehealth in daily practice, and a roadmap of the most relevant legal and ethical issues posed by the spread of telehealth will be traced. In the conclusions, it will be argued that the radical transformations induced by this form of technological innovation call on to a new, ad hoc ethics through which critically evaluate benefits and implications of telehealth services, with a view to keep high the standard of healthcare against the economic interests of private stakeholders and ICTs' vendors.

Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants

OBJECTIVE

The objective of this study was to estimate travel-related and environmental savings resulting from the use of telemedicine for outpatient specialty consultations with a university telemedicine program.

METHODS

The study was designed to retrospectively analyze the telemedicine consultation database at the University of California Davis Health System (UCDHS) between July 1996 and December 2013. Travel distances and travel times were calculated between the patient home, the telemedicine clinic, and the UCDHS in-person clinic. Travel cost savings and environmental impact were calculated by determining differences in mileage reimbursement rate and emissions between those incurred in attending telemedicine appointments and those that would have been incurred if a visit to the hub site had been necessary.

RESULTS

There were 19,246 consultations identified among 11,281 unique patients. Telemedicine visits resulted in a total travel distance savings of 5,345,602 miles, a total travel time savings of 4,708,891 minutes or 8.96 years, and a total direct travel cost savings of $2,882,056. The mean per-consultation round-trip distance savings were 278 miles, average travel time savings were 245 minutes, and average cost savings were $156. Telemedicine consultations resulted in a total emissions savings of 1969 metric tons of CO₂, 50 metric tons of CO, 3.7 metric tons of NO_x, and 5.5 metric tons of volatile organic compounds.

CONCLUSIONS

This study demonstrates the positive impact of a health system's outpatient telemedicine program on patient travel time, patient travel costs, and environmental pollutants.

Governance for health in the Anthropocene

Purpose

The purpose of this paper is to explore the pressing issues facing health and health systems governance in the Anthropocene – a new geological time period that marks the age of colossal and rapid human impacts on Earth’s systems.

Design/methodology/approach

The viewpoint illustrates the extent of various human induced global ecological changes such as climate change and biodiversity loss and explores the social forces behind the new epoch. It draws together current scientific evidence and expert opinion on the Anthropocene’s health and health system impacts and warns that many these are yet unknown and likely to interact and compound each other.

Findings

Despite this uncertainty, health systems have four essential roles in the Anthropocene from adapting operations and preparing for future challenges to reducing their own contribution to global ecological changes and an advocacy role for social and economic changes for a healthier and more sustainable future.

Practical implications

To live up to this challenge, health services will need to expand from a focus on health governance to one on governance for health with a purpose of achieving equitable and sustainable human development.

Originality/value

As cities and local governments work to create more healthy, just and sustainable communities in the years ahead, health systems need to join with them as partners in that process, both as advocates and supporters and – through their own action within the health sector – as leading proponents and models of good practice.

Comparison of access to services in rural emergency departments in Quebec and British Columbia

INTRODUCTION

Although emergency departments (EDs) in Canada's rural areas serve approximately 20% of the population, a serious problem in access to health care services has emerged.

OBJECTIVE

The objective of this project was to compare access to support services in rural EDs between British Columbia and Quebec.

METHODS

Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities (using the rural and small town definition from Statistics Canada). Data were collected from ministries of health, local health authorities, and ED statistics. A telephone interview was administered to collect denominative user data statistics and determine the status of services.

RESULTS

British Columbia has more rural EDs (n  =  34) than Quebec (n  =  26). EDs in Quebec have higher volumes (19,310 versus 7,793 annual visits). With respect to support services, 81% of Quebec rural EDs have a 24/7 on-call general surgeon compared to 12% for British Columbia. Nearly 75% of Quebec rural EDs have 24/7 access to computed tomography versus only 3% for British Columbia. Rural EDs in Quebec are also supported by a greater proportion of intensive care units (88% versus 15%); however, British Columbia appears to have more medevac aircraft/helicopters than Quebec.

CONCLUSIONS

The results suggest that major differences exist in access to support services in rural EDs in British Columbia and Quebec. A nationwide study is justified to address this issue of variability in rural and remote health service delivery and its impact on interfacility transfers and patient outcomes.

Telepractice Versus In-Person Delivery of Voice Therapy for Primary Muscle Tension Dysphonia

PURPOSE

The purpose of this study was to investigate the utility of telepractice for delivering flow phonation exercises to persons with primary muscle tension dysphonia (MTD).

METHOD

Fourteen participants with a diagnosis of primary MTD participated, 7 on site and 7 at remote locations. Each participant received 12 treatment sessions across 6 weeks. Treatment consisted of flow phonation voice therapy exercises. Auditory-perceptual, acoustic, aerodynamic, and quality-of-life measures were taken before and after treatment.

RESULTS

Perceptual and quality-of-life measures were significantly better posttreatment and were statistically equivalent across groups. Acoustic and aerodynamic measures improved in both groups, but changes did not reach statistical significance. Results for the 2 service delivery groups were comparable, with no significant differences observed for perceptual and quality-of-life measures.

CONCLUSIONS

Although the American Speech-Language-Hearing Association supports the use of telepractice for speech-language pathology services, evidence for the use of telepractice for providing behavioral treatment to patients with MTD has been lacking. The results of this study indicate that flow phonation exercises can be successfully used for patients with MTD using telepractice.

Differences in access to services in rural emergency departments of Quebec and Ontario

Introduction

Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers.

Materials and Methods

Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher’s exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario.

Results

All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario’s local population and small town population density. Quebec’s EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers.

Conclusions

Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue.

The Quebec rural emergency department project: a cross-sectional study of a potential two-pronged strategy in the knowledge transfer process

Introduction

Health services research generates useful knowledge. Promotion of implementation of this knowledge in medical practice is essential. Prior to initiation of a major study on rural emergency departments (EDs), we deployed two knowledge transfer strategies designed to generate interest and engagement from potential knowledge users. The objective of this paper was to review: 1) a combined project launch and media press release strategy, and 2) a pre-study survey designed to survey potential knowledge users’ opinions on the proposed study variables.

Materials and Methods

We evaluated the impact of the project launch (presentation at two conferences hosted by key stakeholders) and media press release via a survey of participants/stakeholders and by calculating the number of media interview requests and reports generated. We used a pre-study survey to collect potential key stakeholder’ opinions on the study variables.

Results

Twenty-one of Quebec’s 26 rural EDs participated in the pre-study survey (81% participation rate). The press release about the study generated 51 press articles and 20 media request for interviews, and contributed to public awareness of a major rural research initiative. In the pre-study survey, thirteen participants (46%) mentioned prior knowledge of the research project. Results from the pre-study survey revealed that all of the potential study variables were considered to be relevant for inclusion in the research project. Respondents also proposed additional variables of interest, including factors promoting retention of human resources.

Conclusions

The present study demonstrated the potential utility of a two-pronged knowledge transfer strategy, including a combined formal launch and press release, and a pre-study survey designed to ensure that the included variables were of interest to participants and stakeholders.

Environmental sustainability in hospitals – a systematic review and research agenda

Objectives

Hospitals are significant contributors to natural resource depletion and environmental change. Our objective was to establish the extent to which hospital environmental sustainability has been studied and the key issues that emerge for policy, practice and research.

Methods

The PubMed, Engineering Village, Cochrane and King's Fund databases were searched for articles relating to hospital environmental sustainability published in English between 1 January 1990 and 1 October 2013. Further studies were found by review of reference lists. One hundred ninety-three relevant articles were found and 76 were selected for inclusion in the review.

Results

Common research themes were identified: hospital design, direct energy consumption, water, procurement, waste, travel and psychology and behaviour. Some countries (particularly the United Kingdom) have begun to invest systematically in understanding the environmental effects of hospitals. We found large variability in the extent of the evidence base according to topic. Research regarding the architectural fabric of hospital buildings is at a relatively mature stage. Similarly, there is a developed research base regarding devices and technologies used within hospitals to reduce the environmental effects of direct hospital energy and water use. Less is known about the clinical, psychological and social factors that influence how health care professionals use resources, travel to/from hospital, and interact with the buildings and technologies available. A significant part of the environmental footprint of hospitals relates to clinical practice, e.g. decisions regarding the use of pharmaceuticals and medical devices. Medical ‘cradle to grave’ life cycle assessment studies have been published to understand the full financial and environmental costs of hospital activities. The effects of preventive or demand management measures which avoid unnecessary hospital procedures are likely to be much greater than incremental changes to how hospital procedures are performed.

Conclusions

There remain significant gaps in the evidence base on hospital sustainability. Assessments of environmental impacts and natural resource use are beginning to be produced, both at the level of individual hospitals and at the health system level. These are an important start, but in many areas do not yet provide sufficiently detailed information to guide decision-making. There are many areas where the interests of patients and the environment coincide, but others where tensions exist. Rising resource costs and climate change mitigation measures are likely to create an increasing stimulus for research on hospital sustainability. Such research will benefit from inter-disciplinary coordination across research funders and countries.

A descriptive study of access to services in a random sample of Canadian rural emergency departments

OBJECTIVE

To examine 24/7 access to services and consultants in a sample of Canadian rural emergency departments (EDs).

DESIGN

Cross-sectional study-mixed methods (structured interview, survey and government data bases) with random sampling of hospitals.

SETTING

Canadian rural EDs (rural small town (RST) definition-Statistics Canada).

PARTICIPANTS

28% (95/336) of Canadian rural EDs providing 24/7 physician coverage located in hospitals with acute care hospitalisation beds.

MAIN OUTCOME MEASURES

General characteristics of the rural EDs, information about 24/7 access to consultants, equipment and services, and the proportion of rural hospitals more than 300 km from levels 1 and 2 trauma centres.

RESULTS

Of the 336 rural EDs identified, 122 (36%) were randomly selected and contacted. Overall, 95 EDs participated in the study (participation rate, 78%). Hospitals had, on an average, 23 acute care beds, 7 ED stretchers and 13 500 annual ED visits. The proportion of rural hospitals with local access to the following 24/7 services was paediatrician, 5%; obstetrician, 10%; psychiatrist, 11%; internist, 12%; intensive care unit, 17%; CT scanner, 20%; surgeon, 26%; ultrasound, 28%; basic X-ray, 97% and laboratory services, 99%. Forty-four per cent and 54% of the RST EDs were more than 300 km from a level 1 and level 2 trauma centre, respectively.

CONCLUSIONS

This is the first study describing the services available in Canadian rural EDs. Apart from basic laboratory and X-ray services, most rural EDs have limited access to consultants, advanced imaging and critical care services. A detailed study is needed to evaluate the impact of these limited services on patient outcomes, costs and interfacility transport demands.

Teleconsultations reduce greenhouse gas emissions

OBJECTIVES

Health services contribute significantly to greenhouse gas emissions. New models of delivering care closer to patients have the potential to reduce travelling and associated emissions. We aimed to compare the emissions of patients attending a teleconsultation - an outpatient appointment using video-conferencing equipment - with those of patients attending a face-to-face appointment.

METHODS

We estimated the total distances travelled and the direct and indirect greenhouse gas emissions for 20,824 teleconsultations performed between 2004 and 2011 in Alentejo, a Portuguese region. These were compared to the distances and emissions that would have resulted if teleconsultations were not available and patients had to attend face-to-face outpatient appointments. Estimates were calculated using survey data on mode of transport, and national aggregate data for car engine size and fuel. A sensitivity analysis using the lower and upper quartiles for survey distances was performed.

RESULTS

Teleconsultations led to reductions in distances and emissions of 95%. 2,313,819 km of travelling and 455 tonnes of greenhouse gas emissions were avoided (22 kg of carbon dioxide equivalent per patient). The incorporation of modes of transport and car engine size and fuel in the analysis led to emission estimates which were 12% smaller than those assuming all patients used an average car.

CONCLUSIONS

The availability of remote care services can significantly reduce road travel and associated emissions. At a time when many countries are committed to reducing their carbon footprint, it is desirable to explore how these reductions could be incorporated into technology assessments and economic evaluations.

Environmentally sustainable health and social care: Scoping review and implications for the English NHS

Objectives

To review the evidence on environmental sustainability in health and social care, describe what the implications of sustainability might be for service models and policy, and explore the connection between environmental and financial sustainability.

Methods

Literature review of 78 published articles and qualitative analysis of 28 semi-structured interviews.

Results

Provision of health and social care has a substantial impact on the environment, and opportunities exist at a number of levels to deliver services in a more sustainable way. While there is some scope to improve efficiency at the operational level, significant improvements in sustainability may require a more fundamental transformation in service models, for example, with a stronger emphasis on prevention. The current policy framework in England is perceived to create a number of barriers that discourage professionals from redesigning services in ways which could promote both environmental and financial sustainability.

Conclusions

Increasingly, health and social care will need to be delivered in ways that are not only financially sustainable, but environmentally sustainable too. Close conceptual connections exist with improving productivity – focusing on cost-effectiveness, value and prevention of avoidable activity could enhance sustainability from both an environmental and a financial perspective. Priorities for health care organisations could include prevention, exploring the opportunities presented by new technologies, and improving medicines management and prescribing practices. Policy-makers need to explore what changes are needed to create a more enabling environment, as well as how existing policies can be delivered in the most sustainable way.

Climate change and eHealth: a promising strategy for health sector mitigation and adaptation

Climate change is one of today's most pressing global issues. Policies to guide mitigation and adaptation are needed to avoid the devastating impacts of climate change. The health sector is a significant contributor to greenhouse gas emissions in developed countries, and its climate impact in low-income countries is growing steadily. This paper reviews and discusses the literature regarding health sector mitigation potential, known and hypothetical co-benefits, and the potential of health information technology, such as eHealth, in climate change mitigation and adaptation. The promising role of eHealth as an adaptation strategy to reduce societal vulnerability to climate change, and the link's between mitigation and adaptation, are also discussed. The topic of environmental eHealth has gained little attention to date, despite its potential to contribute to more sustainable and green health care. A growing number of local and global initiatives on ‘green information and communication technology (ICT)’ are now mentioning eHealth as a promising technology with the potential to reduce emission rates from ICT use. However, the embracing of eHealth is slow because of limitations in technological infrastructure, capacity and political will. Further research on potential emissions reductions and co-benefits with green ICT, in terms of health outcomes and economic effectiveness, would be valuable to guide development and implementation of eHealth in health sector mitigation and adaptation policies.