The empirical foundations of telemedicine interventions for chronic disease management

Telemedicine in Cardiology: Enhancing Access to Care and Improving Patient Outcomes

Telemedicine has gained significant recognition, particularly since the COVID-19 pandemic. However, its roots date back to its significant role during major epidemic outbreaks such as severe acute respiratory syndrome (SARS), H1N1 and H7N9 influenza, and Middle East respiratory syndrome (MERS), where alternate means of accessing healthcare were adopted to combat the outbreak while limiting the spread of the virus. In Sub-Saharan Africa, telemedicine has supported healthcare delivery, patient and professional health education, disease prevention, and surveillance, starting with its first adoption in Ethiopia in 1980. In the United States, telemedicine has significantly impacted cardiology, particularly at-home monitoring programs, which have proven highly effective for patients with abnormal heart rhythms. Devices such as Holter monitors, blood pressure monitors, and implantable cardioverter-defibrillators have reduced mortality rates and hospital readmissions while improving healthcare efficiency by saving healthcare costs. However, the COVID-19 pandemic accelerated the adoption of telemedicine, as evidenced by a dramatic increase in telemedicine visits at institutions like New York University (NYU) Langone Health during and post-COVID-19 pandemic. In addition, telemedicine has also facilitated cardiac rehabilitation and improved access to specialized cardiology care in rural and underserved areas, reducing disparities in cardiovascular health outcomes. As technology advances, telemedicine is poised to play an increasingly significant role in cardiology and healthcare at large, enhancing patient management, healthcare efficiency, and cost reduction. This review underscores the significance of telemedicine in cardiology, its challenges, and future directions.

Augmenting K-Means Clustering With Qualitative Data to Discover the Engagement Patterns of Older Adults With Multimorbidity When Using Digital Health Technologies: Proof-of-Concept Trial

BACKGROUND

Multiple chronic conditions (multimorbidity) are becoming more prevalent among aging populations. Digital health technologies have the potential to assist in the self-management of multimorbidity, improving the awareness and monitoring of health and well-being, supporting a better understanding of the disease, and encouraging behavior change.

OBJECTIVE

The aim of this study was to analyze how 60 older adults (mean age 74, SD 6.4; range 65-92 years) with multimorbidity engaged with digital symptom and well-being monitoring when using a digital health platform over a period of approximately 12 months.

METHODS

Principal component analysis and clustering analysis were used to group participants based on their levels of engagement, and the data analysis focused on characteristics (eg, age, sex, and chronic health conditions), engagement outcomes, and symptom outcomes of the different clusters that were discovered.

RESULTS

Three clusters were identified: the typical user group, the least engaged user group, and the highly engaged user group. Our findings show that age, sex, and the types of chronic health conditions do not influence engagement. The 3 primary factors influencing engagement were whether the same device was used to submit different health and well-being parameters, the number of manual operations required to take a reading, and the daily routine of the participants. The findings also indicate that higher levels of engagement may improve the participants' outcomes (eg, reduce symptom exacerbation and increase physical activity).

CONCLUSIONS

The findings indicate potential factors that influence older adult engagement with digital health technologies for home-based multimorbidity self-management. The least engaged user groups showed decreased health and well-being outcomes related to multimorbidity self-management. Addressing the factors highlighted in this study in the design and implementation of home-based digital health technologies may improve symptom management and physical activity outcomes for older adults self-managing multimorbidity.

The Impact of Telemedicine and Remote Patient Monitoring on Healthcare Delivery: A Comprehensive Evaluation

Background Telemedicine and remote patient monitoring have emerged as transformative solutions in contemporary healthcare. This study aimed to conduct a comprehensive evaluation of the impact of these technologies on healthcare delivery, focusing on patient outcomes, economic parameters, and overall satisfaction. Methods A prospective observational study was conducted in various healthcare facilities, involving 186 participants with chronic diseases. Inclusion criteria included patients actively using telemedicine services. Data collection methods included surveys, interviews, and review of medical records, focusing on patient demographics, clinical outcomes, and economic parameters. The intervention involved a seamless integration of telemedicine technologies into the existing health system. Results Primary outcomes revealed significant improvements in patient health, including a decrease in disease-specific markers (mean reduction of 12,000 to 11,000, p = 0.002), a substantial reduction in severity of symptoms (mean reduction from 3,500 to 2,500, p < 0.001), and a general improvement in health status (mean increase from 7,200 to 8,500, p < 0.001). The savings in healthcare costs were evident, with direct costs decreasing from 25,000 to 12,000 (p < 0.001) and indirect costs decreasing from <10,000 to <5,000 (p = 0.004). Secondary results demonstrated increased patient satisfaction with communication (increase from 80% to 95%, p < 0.001) and convenience of services (increase from 75% to 90%, p < 0.001). Patient satisfaction also increased significantly (from 80% to 95%, p < 0.001). Accessibility to healthcare services improved, with a reduction in geographic barriers (increase from 65% to 90%, p < 0.001) and a decrease in the frequency of healthcare utilization (decrease from 2.5 to 1.5, p < 0.001). Conclusion The study provides robust evidence of the positive impact of telemedicine and remote patient monitoring on healthcare delivery. Significant improvements in patient outcomes, coupled with substantial cost savings and increased satisfaction levels, underscore the transformative potential of these technologies.

Teledermatology in Atopic Dermatitis: A Systematic Review

Telemedicine use has been increasing especially during the COVID-19 pandemic. Various studies have outlined benefits of telemedicine including improving health equity, reducing wait times, and cost-effectiveness. Skin diseases such as atopic dermatitis (AD) may potentially be managed via telemedicine. However, there are no evidence-based recommendations for best practices in telemedicine for assessing AD patients. The objective of this review is to assess and summarize current evidence on telemedicine modalities for AD. This review will assess patient outcomes from various telemedicine models for AD. A review protocol was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Two reviewers independently screened potential studies and extracted data. Studies were included if they evaluated any telemedicine assessment for AD. Of 2719 identified records, 5 reports were included. Two reports used the direct-access online model, 1 used web-based consultation, 1 used e-health through a personal eczema portal, and 1 used an online platform and mobile application. All models were variations of the asynchronous, store and forward model. In all the included reports, teledermatology for the follow-up of patients with AD was effective and equivalent when compared to in-person appointments or standard treatment for their respective key outcome measures. However, it is unclear what the most effective teledermatology model is due to significant heterogeneity between studies. Teledermatology may serve as an important tool for triaging and follow-up of patients with AD. More studies are needed to determine which teledermatology models are most effective for virtual assessment of AD.

Evaluation of the Effectiveness of Telemedicine in Postoperative Follow-Up Care After Dental Implant Surgery. A Pilot Study

Aim

Telemedicine has emerged as a potential solution to enhance postoperative follow-up care after dental implant surgery, offering the convenience of remote monitoring and reduced need for in-person visits.

Materials and Methods

Participants were randomly assigned to either the telemedicine group (n = 15) or the in-person group (n = 15). In the telemedicine group, patients received remote follow-up care through virtual consultations, during which they could communicate their concerns and share images of the surgical site. The in-person group received standard in-person follow-up visits. Patient satisfaction was measured using a standardized survey, with responses collected on a Likert scale.

Results

Telemedicine group exhibited comparable levels of patient satisfaction (mean satisfaction score ± standard deviation: 4.6 ± 0.3) to the in-person group (4.7 ± 0.2). Moreover, clinical outcomes, including wound healing assessment, were similar between the two groups. No significant differences were observed in the incidence of postoperative complications or the need for additional interventions.

Conclusion

In conclusion, this pilot study demonstrates that telemedicine is an effective alternative to traditional in-person follow-up care for postoperative dental implant surgery patients. It offers comparable patient satisfaction and clinical outcomes while proving to be more cost-effective.

Telemedicine interventions for older adults: A systematic review

INTRODUCTION

Telemedicine may help improve older adults' access, health outcomes, and quality of life indicators. This review aims to provide current evidence on the effectiveness of telemedicine in the aged population.

METHOD

A systematic literature search was conducted in PubMed, Google Scholar, and Web of Science electronic databases between January 2015 and September 2021 using the keywords "telemedicine" or "telehealth" and "older people" or "geriatrics" or "elderly." The articles were classified under three headings according to the purposes: feasibility, diagnosis and management of chronic diseases, and patient satisfaction.

RESULTS

A total of 22 articles were included. Across most disciplines, evidence has shown that telemedicine is as effective as usual care, if not more so, in the feasibility, chronic disease management, and patient satisfaction of the elderly. However, a few studies reported challenges such as difficulty with technology, hearing problems, and the inability to perform hands-on examinations for physicians.

CONCLUSION

Findings from this review support the view that health care providers can use telemedicine to manage elderly individuals in conjunction with usual health care. However, future research is needed to eliminate barriers to increasing telemedicine use among older adults.

The Role of Teleconsultations in Remote Oral Radiology Interpretation

Background

Teleconsultations have gained prominence as a viable method for delivering medical services remotely. In oral radiology, the ability to interpret radiographic images accurately is crucial for diagnosing and treating various dental conditions. The use of teleconsultations in this domain holds promise for extending specialized care to patients who are geographically distant from dental healthcare facilities.

Materials and Methods

A total of 50 patients' oral radiographic images were collected for analysis in this study. These images were obtained from diverse geographical locations, showcasing the applicability of teleconsultations. Two groups of dental professionals, one conducting in-person evaluations and the other performing remote interpretations through teleconsultations, participated in the study. The radiographic findings were assessed for concurrence between the two groups. Statistical analysis included the calculation of P values to determine the level of agreement between the in-person and teleconsultation interpretations.

Results

The results of this study revealed a substantial level of agreement between in-person and teleconsultation interpretations of oral radiographic images. The calculated P values indicated a statistically significant concordance between the two evaluation methods (P < .05). This suggests that teleconsultations can be a reliable approach for oral radiology interpretation, offering comparable results to traditional in-person evaluations.

Conclusion

In conclusion, teleconsultations have demonstrated their potential as an effective means of interpreting oral radiographic images remotely.

Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

General Public Perceptions and Perceived Barriers Toward the Use of Telehealth: A Cross-Sectional Study from Jordan

Background: Telemedicine implies the provision of health care services, such as diagnosis, treatment, and consultation related to different disease states remotely through harnessing a variety of technologies. Aim: Despite the widespread global applications related to telehealth, there are limited research articles exploring the perceptions and barriers related to telehealth implementation in developing countries such as Jordan. Thus, this study was conducted to explore general public perceptions regarding the provision of health care services through different technological devices and to examine perceived barriers and facilitators. Methods: A cross-sectional study was conducted for 6 months. Participants were recruited through different social media portals. A convenient sample from the Jordanian population was approached. A total of 1,136 responses were collected and included in the final analysis, which was done by the Statistical Package for Social Sciences (SPSS version 25). Results: A total of 1,136 responses were valid for further analysis. The results of this study expressed that the public has positive perceptions toward the use of telemedicine with the majority being capable of using telehealth based on having an active internet connection, technological devices, and the ability to use social media accounts or instant messaging services. Logistic regression analysis revealed that those with comorbid diseases and higher summated capability scores (p = -0.017 and p < 0.001, respectively) had a statistically significant relationship with willingness to use telehealth as reflected by stating a clear intention to use telehealth services once available. Conclusion: In conclusion, the Jordanians had positive perceptions toward the use of telehealth services. However, their willingness to use telehealth services was affected by limited knowledge about the service. Telehealth offers the opportunity to provide quality care and improve patient outcomes, especially for the inhabitants of rural areas or in cases where access to health care facilities is compromised such as pandemics.

Preferences and willingness-to-pay for a blood pressure telemonitoring program using a discrete choice experiment

This study aimed to elicit the preferences and willingness-to-pay for blood pressure (BP) telemonitoring programs. This study also investigated the different factors or participant characteristics that could influence preferences and choice behaviors. Participants with hypertension were identified from an online survey panel demographically representative of Singapore's general population. Participants completed a discrete choice experiment (DCE) with 12 choice sets, selecting their preferred BP monitoring program differing on five attributes: mode of consultation, BP machine type (with Bluetooth or not), BP machine price, monthly fee, and program duration. The base reference population (male, married, higher income, more formal education years, full-time worker, aged 55 to <65 years, and digital skills score of 36) preferred teleconsultation over in-person consultation, Bluetooth feature, lower machine price, lower monthly fee, and shorter program duration. A subgroup of participants can be considered teleconsultation-resistant, and three demographic factors were associated with lower preference for teleconsultation: female, fewer formal education years, and lower income. Considering the reference population and Bluetooth attribute, participants were willing to pay 66 SGD (~49 USD) additional for the machine to obtain the Bluetooth feature. Considering the reference population and teleconsultation attribute, participants were willing to pay 6.80 SGD (~5.10 USD) extra monthly fee for a program using teleconsultation. Here we report that amongst participants with hypertension, there is strong preference for the use of teleconsultation and a BP machine with Bluetooth feature in a BP monitoring program. However, a subgroup of participants are teleconsultation-resistant and would prefer in-person consultation.

A scoping review on the factors associated with the lost to follow-up (LTFU) amongst patients with chronic disease in ambulatory care of high-income countries (HIC)

BACKGROUND

Despite the importance of long term follow-up care for patients with chronic disease, many patients fail to adhere to their follow-ups, which increase their risk of further health complications. Therefore, the purpose of this scoping review was to find out the factors associated with lost to follow-up (LTFU) amongst patients with chronic disease in the ambulatory care setting of high-income countries (HICs) to gain insights for better quality of care. Understanding the definition of LTFU is imperative in informing patients, health professionals and researchers for clinical and research purposes. This review also provided an overview of the terms and definitions used to describe LTFU.

METHODS

The following databases: CINAHL, EMBASE, Medline, PsycINFO and Web of Science were searched for studies investigating the factors associated to LTFU from the date of inception until 07 January 2022.

RESULTS

Five thousand one hundred and seven records were obtained across the databases and 3,416 articles were screened after removing the duplicates. 25 articles met the inclusion criteria, of which 17 were cohort studies, five were cross-sectional studies and three were case-control studies. A total of 32 factors were found to be associated with LTFU and they were categorised into patient factors, clinical factors and healthcare provider factors.

CONCLUSION

Overall, the factors associated with LTFU were generally inconsistent across studies. However, some factors such as financial factors (i.e., no insurance coverage) and low accessibility of care were consistently associated with LTFU for both mental and physical chronic conditions. The operational definitions of LTFU also varied greatly across studies. Given the mixed findings, future research using qualitative aproaches would be pivotal in understanding LTFU for specific chronic diseases and the development of targeted interventions. Additionally, there is a need to standardise the operational definition of LTFU for research as well as clinical practice purposes.

Impact of Telehealth and Process Virtualization on Healthcare Utilization

Telehealth has emerged as a tool to improve patient access by virtualizing healthcare services, particularly during the COVID-19 pandemic. However, concerns have been raised that telehealth may actually increase healthcare spending by leading to new types of utilization. Our research provides empirical evidence that this concern is unfounded based on a state-wide study of patient visit-level data of telehealth use in 58 hospitals in Maryland from 2012 to 2021. On average, telehealth use can reduce future outpatient visits by 13.6% within 30 days after a telehealth visit, leading to a cost reduction of $239. The benefits of telehealth are most apparent for diseases with high potential for process virtualization, such as mental health, skin disorders, metabolic, and musculoskeletal diseases. Although telehealth has a substitution effect on future healthcare utilization, this effect is not observed among rural patients who use telehealth as a gateway to utilize more primary care and specialist services. Our findings suggest that policymakers should promote the use of telehealth in a value-based healthcare environment by providing monetary incentives to expand telehealth use among patients and providers, and expand the scope of telehealth services to include consultation with specialists especially among rural patients.

Personalized Telehealth: Redesigning Complex Care Delivery for the 65+ During the COVID Pandemic: a Survey of Patients, Caregivers, and Health-care Providers

Background

In the context of the ongoing COVID-19 pandemic, rapid transitions have been made towards telehealth. Optimal use of telehealth in elderly patients remains poorly understood and adaptation challenges persist. Our study aimed at identifying perceptions, barriers, and possible facilitators to telehealth use amongst elderly patients with comorbidities, their caregivers, and health-care providers (HCPs).

Methods

Health-care providers, patients 65 years and older with multiple comorbidities, and caregivers were recruited from outpatient clinics and invited to complete an electronic self-administered or telephone-administered survey on their perceptions of telehealth and of barriers to its implementation.

Results

A total of 39 health-care providers, 40 patients, and 22 caregivers responded to the survey. Most patients (90%), caregivers (82%), and HCPs (97%) had experienced telephone visits, but few were conducted via videoconference platforms. Patients and caregivers showed interest in pursuing some future telehealth visits (68%, 86%, respectively), but felt they lacked access to technology and skills (n=8, 20%), and some felt that telehealth visits may be inferior to in-person visits (n=9, 23%). HCPs showed interest in incorporating telehealth visits into practice (n=32, 82%), but identified challenges in lack of administrative support (n=37), lack of HCP (n=28) and patient (n=37) technological skills, and limited infrastructure (n=37)/internet access (n=33).

Conclusions

Older patients, caregivers, and HCPs show interest in pursuing future telehealth visits but elucidate similar barriers. Facilitating access to technology, as well as to administrative and technology support guides, could promote high quality and equal access to virtual care for the older adult.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study

BACKGROUND

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access.

METHODS

Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes.

RESULTS

Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances.

INTERPRETATION

Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

The impact of lockdown on symptoms and health status of patients with chronic airway diseases: An appraisal of patient perceived impressions

Background

The pandemic-specific lockdown may influence the health status of patients with chronic airflow obstruction (CAO) as COPD, COPD-PH, and chronic asthma.

Objectives

To find the impact of the lockdown on symptoms, and the degree of perceived change in physical activity and emotional health with possible reasons including the indicators of ambient air pollution.

Methods

A cohort of CAO patients was telephonically enquired regarding their perceived well-being in symptom status, physical activity, and emotional health with the perceived contribution from plausible reasons (regular medication, simple food, no pollution, and family attention) for the change; all being expressed in percentages. The change in symptom scores as 0-39, 40-79, and 80-100 were regarded as 'low', 'medium', and 'high' respectively. The impact of the individual contributing factor was calculated statistically. The assessment of the CAT (COPD assessment test) score and the ambient air pollution (PM2.5 and PM10) was also done for their association with well-being.

Results

There was a universal improvement (p < 0.5) in COPD (n = 113), COPD-PH, (n = 40), and chronic asthma, (n = 19) as regards symptoms, physical activity, and emotional health that tallies to overall and individual change in CAT score. There were concomitant reductions in PM10 and PM2.5 levels during the lockdown compared to the same period of the previous year. All the four listed factors contributed with the 'no/low pollution' and 'simple food being the most important; on acting together, they reduced the moderate and severe symptoms impressively.

Conclusion

Reduced air pollution and simple food appear most important for the improvement of CAO patients during the lockdown period.

Analyzing the Effectiveness of mHealth to Manage Diabetes Mellitus Among Adults Over 50: A Systematic Literature Review

Purpose

A total of 537 million suffered from diabetes mellitus in 2021, and the aging of the population will not abate this number in the future. Diabetes predisposes people to ailments and doubles the risk of COVID-19 mortality. mHealth has shown promise to help manage diabetes. The aim of this review is to objectively analyze research from the last 2.5 years to assess effectiveness where mHealth has been used as an intervention to help manage diabetes in older patients. We also analyzed patient satisfaction, quality, and barriers to adoption of mHealth to manage diabetes.

Patients and Methods

No human subjects were involved in this review. We queried four research databases for mHealth to manage diabetes in older adults. We conducted the review based on the Kruse Protocol for writing as systematic review and we reported our findings in accordance with PRISMA (2020).

Results

Thirty research articles from 11 countries were analyzed. Five interventions of mHealth were identified. Of these mHealth Short Message service (SMS) helped change behavior and encouraged self-care. mHealth SMS coupled with telemedicine for coaching showed positive effects on weight loss, BMI, diet, exercise, HbA1C, disease awareness, blood pressure, cholesterol, medication adherence, and foot care.

Conclusion

mHealth SMS coupled with telemedicine for coaching shows the greatest promise for educating, changing behavior, and realizing positive outcomes across a broad spectrum of health factors. The largest drawback is the cost of acquiring equipment and training users.

Construction and application of tuberculosis medical and nursing integration cooperation model

OBJECTIVE

To explore the clinical effect of the tuberculosis (TB) doctor-nurse integration management model METHODS: This study is a retrospective historical cohort study. The clinical data of 180 patients with TB in our hospital from 2019 to 2020 were analyzed retrospectively. In a control group, 90 cases were treated with the traditional medical care model. An observation group of 90 cases received clinical diagnoses, treatments, and nursing under a doctor-nurse integration management model. Comparative analyses between the two groups were conducted on various aspects, including the awareness level of TB prevention and control, medication compliance and patient satisfaction. Comparisons between the two groups were evaluated using independent-sample t-tests or Chi-squared tests RESULTS: Compared with the control group, the knowledge awareness levels of TB prevention and medication compliance in the observation group were significantly higher (p < .05). The appointment waiting times and hospitalization times in the observation group were significantly lower than in the control group (p < .05). The total average satisfaction score of the patients in the observation group was significantly higher than in the control group (p < .05). Compared with the control group, the patients in the observation group were significantly more satisfied with their nursing methods, operating techniques, psychological techniques, service attitudes, and ward management (p < .05). In addition, in the observation group, medical-nursing relationships and doctor-patient communication were better than in the control group; additionally, the satisfaction of doctors with nursing work was also higher than in the control group, which was a statistically significant difference (p < .05) CONCLUSION: The implementation of an integrated medical-nursing cooperation model for TB will help increase the awareness of health knowledge in patients with TB, improve patient medication compliance and enhance patient satisfaction.

A história da telemedicina no Brasil: desafios e vantagens

Resumo A utilização de novas tecnologias de informação para um atendimento mais efetivo e à distância é algo que se impõe no contexto de serviços em saúde, no atual panorama sociopolítico. Entretanto, o Brasil ainda está receoso em integrar de forma permanente esses avanços. Esta pesquisa tem como objetivo revisar os marcos da história da telemedicina no Brasil, destacando as questões éticas e legislativas, bem como evidenciar os desafios para sua implantação e gerar uma proposta para superá-los. Trata-se de uma revisão integrativa da literatura acerca da história, dos desafios e da realidade da telemedicina no cenário brasileiro. A telemedicina é uma atividade recente no Brasil, defrontando-se com resistências por parte dos profissionais, em especial médicos, que diversas vezes não vislumbram claramente seus benefícios. Apesar das dificuldades previstas em aceitar este modelo, é relevante ressaltar as vantagens que esse padrão abarca, como ampliar e facilitar o acesso à assistência de saúde. Propor alternativas para superar resistências e alcançar um padrão otimizado é essencial e abrange maior abertura no campo político, legislativo e educacional.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Effectiveness and cost-effectiveness of a telemedicine programme for preventing unplanned hospitalisations of older adults living in nursing homes: the GERONTACCESS cluster randomized clinical trial

OBJECTIVE

The GERONTACCESS trial evaluated the utility and cost-effectiveness of a gerontological telemedicine (TLM) programme for preventing unplanned hospitalisation of residents living in nursing homes (NHs) in regions lacking medical facilities and/or qualified medical providers ("medical deserts").

DESIGN

GERONTACCESS was a 12-month, multicentre, prospective cluster-randomised trial conducted in NHs. The intervention group underwent TLM assessments every 3 months. The control group received the usual care. In both groups, comprehensive on-site assessments were conducted at baseline and the final visit. Care requirements were documented throughout the study.

SETTING AND PARTICIPANTS

NH residents aged ≥ 60 years with multiple chronic diseases.

METHODS

The study outcomes were the proportion of patients who experienced avoidable and unplanned hospitalisation, and the incremental cost savings per quality-adjusted life years from baseline to the 12-month follow-up.

RESULTS

Of the 426 randomised participants (mean ± standard deviation age, 87.2 ± 7.6 years; 311 [73.0%] women), 23.4% in the intervention group and 32.5% in the control group experienced unplanned hospitalisation (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.43 to 0.97; p = 0.034). Each avoided hospitalisation in the intervention group saved $US 3,846.

CONCLUSIONS AND IMPLICATIONS

The results of GERONTACCESS revealed that our gerontological, preventative TLM program significantly reduced unplanned hospitalisations. This innovative intervention limited disease progression and promoted a healthy lifestyle among NH residents.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02816177, registered June 28, 2016.

Individually tailored home-based physiotherapy program makes sustainable improvement in exercise capacity and daily physical activity in patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare, chronic, progressive, and life-threatening cardiopulmonary disease. This study investigated the impact of an individually tailored 12 weeks home-based physiotherapy program in PAH patients, with the aim to evaluate change in exercise capacity and daily physical activity level.

METHODS

This was an analysis of secondary outcomes from a prospective, randomized, controlled intervention study. Twenty-one participants were recruited from the Latvian PH registry based on inclusion criteria and randomized in a training group (TG) and control group (CG). Both groups continued a medical target therapy, but for TG, the individually tailored home-based physiotherapy program was added including physical exercises, relaxation, self-control, education, and supervision with telehealth elements. Outcomes included a 6-min walk test (6MWT) (m) and daily physical activity based on accelerometry results assessed at baseline, after 12 weeks, and at follow-up 6 months after commencement of intervention.

RESULTS

6MWT distance significantly (p < 0.05) and clinically (>33 m) increased within TG after 12 weeks (51.8 m, 95% CI = 25.7-77.9 m, Cohen's d = 1.7) and at follow-up (75.5 m, 95% CI = 46.1-104.8 m, Cohen's d = 2.1). A significant difference in 6MWT results between the groups at 12 weeks and follow-up was approved. In TG, low-intensity activities significantly (p < 0.05) increased both after 12 weeks (Cohen's d = 1.6) and at follow-up (Cohen's d = 1.2), moderate-intensity activities significantly (p < 0.05) increased at follow-up (Cohen's d = 1.3), and no significant improvements were present in CG.

CONCLUSION

The individually tailored 12 weeks home-based physiotherapy program comprising comprehensive physical exercise training, relaxation, self-control skills training, and education, added to stable medical target therapy and supervised by physiotherapist through telehealth elements, is effective in improving exercise capacity and increasing daily time in low or moderate physical activities 6 months after commencement of the intervention in patients with PAH.

Nursing Home-Sensitive Hospitalizations and the Relevance of Telemedicine: A Scoping Review

The aging of society is increasing the number of hospitalizations of nursing home residents. Telemedicine might help reduce the frequency of these potentially risk-associated hospitalizations. This scoping review looked for evidence of a change in the rate of hospitalization and, if mentioned, any cost savings and/or staff acceptance of the use of telemedicine in a nursing home setting. To identify available evidence, the electronic databases PubMed, Livivo, EBSCO and JSTOR were searched (without time or regional constraints) for comparative primary research studies on this topic in peer-reviewed journals. A total of 1127 articles were retrieved and 923 titles and abstracts were screened, with 16 studies published between 2001 and 2022 being included. Telemedicine consultation reduced the hospitalization of nursing home residents in 14/16 and care costs in 8/11 articles. Staff satisfaction was mentioned positively in five studies. Most studies used telemedicine involving medical diagnostic technologies (10), (electronic) health records (9), specialists (9) and specialized nursing staff (11). Few studies had a higher level of evidence: only one randomized clinical trial was included. There is the need for high credibility studies, using guidelines on protocol and reporting, to better understand the hindering and facilitating factors of telemedicine provision in the healthcare of nursing home residents.

Association Between In-Person vs Telehealth Follow-up and Rates of Repeated Hospital Visits Among Patients Seen in the Emergency Department

Importance

For patients discharged from the emergency department (ED), timely outpatient in-person follow-up is associated with improved mortality, but the effectiveness of telehealth as follow-up modality is unknown.

Objective

To evaluate whether the rates of ED return visits and hospitalization differ between patients who obtain in-person vs telehealth encounters for post-ED follow-up care.

Design, Setting, and Participants

This retrospective cohort study included adult patients who presented to either of 2 in-system EDs of a single integrated urban academic health system from April 1, 2020, to September 30, 2021; were discharged home; and obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days).

Exposures

In-person vs telehealth post-ED discharge follow-up within 14 days.

Main Outcomes and Measures

Multivariable logistic regression was used to estimate the odds of ED return visits (primary outcome) or hospitalization (secondary outcome) within 30 days of an ED visit based on the modality of post-ED discharge follow-up. Models were adjusted for age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, ambulatory billing codes for the index visit, and the time from ED discharge to follow-up.

Results

Overall, 12 848 patients with 16 987 ED encounters (mean [SD] age, 53 [20] years; 9714 [57%] women; 2009 [12%] Black or African American; 3806 [22%] Hispanic or Latinx; and 9858 [58%] White) were included; 11 818 (70%) obtained in-person follow-up, and 5169 (30%) obtained telehealth follow-up. Overall, 2802 initial ED encounters (17%) led to returns to the ED, and 676 (4%) led to subsequent hospitalization. In adjusted analyses, telehealth vs in-person follow-up visits were associated with increased rates of ED returns (28.3 [95% CI, 11.3-45.3] more ED returns per 1000 encounters) and hospitalizations (10.6 [95% CI, 2.9-18.3] more hospitalizations per 1000 encounters).

Conclusions and Relevance

In this cohort study of patients in an urban integrated health care system, those with telehealth follow-up visits after an ED encounter were more likely to return to the ED and be hospitalized than patients with in-person follow-up. The use of telehealth warrants further evaluation to examine its effectiveness as a modality for continuing care after an initial ED presentation for acute illness.

Determining the Factors that Impede or Facilitate the Utilization of Telemedicine (Video Visits) for Geriatric Patients

Objective

The objective of the study was to evaluate the barriers and facilitators of telemedicine utilization experienced by geriatric patients at the University of Iowa Family Medicine Clinic and selected Senior Living Communities in Iowa City, to inform recommendations for improving the telemedicine delivery process for older adults.

Methods

The study population was elderly patients (65-85 years old) living independently, and in long-term care facilities, who received health care using telemedicine during the period of the study from March to July 2020. A Mixed Methods study design was utilized with qualitative data collected through semistructured telephone and Zoom interviews and quantitative data through surveys.

Results

A total of 33 study participants (n = 33) were interviewed or surveyed, including 3 patients (n = 3), 4 caregivers (n = 4), 19 physicians (n = 19), 5 medical assistants (n = 5), and 2 schedulers (n = 2). The results showed that geriatric patients and their caregivers, as well as health and nonhealth care personnel experience barriers, including difficulty navigating technology, privacy concerns, and lack of technical support; and facilitators, such as customer service support and having protocols to guide patients on telemedicine use.

Conclusion

Geriatric patients face certain barriers and facilitators (self-identified or identified by their caregivers, physicians, and other health and nonhealth care personnel) that can make it either more or less difficult for them to maximize the benefits of telemedicine. As a result, health systems should consider older adults' needs and preferences when implementing telemedicine systems in outpatient settings.

Measurement Properties of Remotely or Self-Administered Lower Extremity Mobility Performance Measures in Adults: A Systematic Review

OBJECTIVE

For individuals who face barriers to care assessment, there is a need for remote administration or self-administration of physical performance measures that assess mobility to determine current functional status and to monitor and predict future changes in functional status. The primary purpose of this review is to evaluate the available measurement properties of scores for remotely or self-administered lower extremity mobility performance measures in adults. This review also outlines the test procedures and population suitability of these measures.

METHODS

Data sources were Ovid MEDLINE, Ovid Embase, EBSCOhost CINAHL, Ovid AMED, and Cochrane CENTRAL-which were searched from inception to January 26, 2021-and the reference lists of relevant studies. Two individuals independently screened studies that assessed at least 1 prespecified measurement property of scores for a remote and/or self-administered lower extremity physical performance measure assessing mobility in an adult population. Two individuals independently extracted data on study characteristics, measurement properties, feasibility, and interpretability using piloted extraction forms. The COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) Risk of Bias tool was used to assess methodological quality. Data were qualitatively summarized, and results were compared against COSMIN's criteria for good measurement properties. Level of evidence was determined using COSMIN's modified GRADE approach.

RESULTS

Fourteen studies detailing 19 outcome measures were included. Many studies displayed "sufficient" measurement properties based on COSMIN's criteria; however, risk of bias for most of the included studies was rated adequate or doubtful.

CONCLUSION

Clinicians and researchers can consider the measurement properties of scores and feasibility of different approaches presented in this review when determining how to assess or monitor mobility in adult populations.

IMPACT

Assessing mobility via remote or self-administered physical performance measures in adult populations appears to be feasible using a variety of methods including simple tools (chair, stopwatch), videoconferencing, and smartphone applications. This strategy may be particularly valuable for self-management of chronic conditions and decreasing barriers to accessing care.

Using Video Telehealth to Deliver Patient-Centered Collaborative Care: The G-IMPACT Pilot

Objectives: This pilot project aimed to explore a new model of healthcare delivery to older adult medically complex Veterans by combining telehealth technology with an interdisciplinary medical team operating in real time.Methods: The Geriatric-Interdisciplinary Mobile Patient Access Team (G-IMPACT) was comprised of a field team including a nurse practitioner and technology assistant who visited enrolled patients in their homes using synchronous video to link to a suite of geriatric specialists in a video-enabled room at a Veterans Affairs hospital. Clinicians interacted with patients, caregivers, and each other to develop mutually agreed upon treatment plans that were then immediately implemented in the field.Results: 11 total visits were conducted with 9 Veteran patients aged 55-91 (mean = 75.3 years). Both patients and clinicians reported a high level of satisfaction across multiple metrics, including visit quality, and positive indirect indicators of effectiveness were apparent from qualitative data.Conclusions: Nurse practitioner facilitated video visits allowed geriatric patients to meet with multiple specialists simultaneously with both high patient satisfaction and increased real-time care coordination.Clinical Implications: This project identified challenges and opportunities afforded by this type of real-time telehealth care delivery and can inform the development of future interdisciplinary mobile medical teams.

In patients admitted to a home rehabilitation service, is remote completion of the PG-SGA physical examination using still images captured by Allied Health Assistants a valid alternative to an in-person physical examination?

BACKGROUND

There is increasing provision of telehealth services, including nutrition services. However remote nutrition assessments are challenging due to difficulties in conducting physical assessments remotely, a crucial component of assessing nutritional status.

OBJECTIVE

The aim of this study was to evaluate whether remote completion of the PG-SGA physical examination using still images captured by Allied Health Assistants is a valid alternative to an in-person physical examination in patients admitted to a home rehabilitation service.

DESIGN

This study was Cross-sectional in design.

PARTICIPANTS/SETTING

This study involved 104 adults admitted to the home-rehabilitation service at Southern Adelaide Local Health Network, Adelaide Australia over two sampling periods in 2019 and 2020 who were receiving home visits by an AHA and were engaged in rehabilitation activities.

MAIN OUTCOME MEASURES

Validity of the still-image based physical assessment was determined using still-images collected by an AHA and an in-person physical assessment completed by a dietitian from each participant. A dietitian blinded to the in-person results later assessed the de-identified still-images to determine the presence and extent of deficit at each anatomical site and overall physical examination component of the Patient-generated subjective global assessment (PG-SGA).

STATISTICAL ANALYSES PERFORMED

Percentage agreement, weighted kappa, sensitivity and specificity between the still-image based and in-person physical examinations were determined to assess agreement between the two methods of assessment.

RESULTS

The still-image based physical examination achieved a percentage agreement of 75% against the in-person examination, with a weighted kappa of 0.662 (0.516, 0.808) and a sensitivity-specificity pair of 76.6% and 89.1%.

CONCLUSIONS

Physical examination using still-images collected by AHAs achieved percentage agreement, kappa and sensitivity and specificity compared to an in-person physical examination that is consistent with or superior to commonly adopted nutrition screening and assessment tools. There is potential for implementation of this method to facilitate remote nutritional assessments by dietitians however further work is needed to ensure dietitians are able to assess still-images reliably.

Effects of home-based telehealth on the physical condition and psychological status of patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIMS

This systematic review and meta-analysis aimed to evaluate the effects of home-based telehealth compared with usual care on six-minute walking distance (6MWD), health-related quality of life, anxiety and depression in patients with chronic obstructive pulmonary disease.

METHODS

We identified randomized controlled trials through a systematic multidatabase search. Titles and abstracts were assessed for relevance. Two authors independently extracted data and assessed the risk of bias and quality of evidence. Meta-analyses were conducted using Review Manager and Stata.

RESULTS

We included 32 randomized controlled trials (n = 5232). Devices used for home-based telehealth interventions included telephones, videos, and combined devices. The quality of the evidence was downgraded due to high risk of bias, imprecision, and inconsistency. Home-based telehealth significantly increased 6MWD by 35 m (SD = 30.42) and reduced symptom burden by 3 points (SD = -2.30) on the COPD assessment test compared with usual care. However, no significant differences in anxiety and depression were noted between the home-based telehealth group and the standard care group. In subgroup analysis, home-based telehealth significantly improved 6MWD and health status after 6-12 months and >12 months.

CONCLUSION

Low quality evidence showed that home-based telehealth interventions reduce symptom burden and increase walking distance to a clinically meaningful extent in patients with COPD. However, no effects on depression and anxiety were observed.

Moving Towards Equity With Digital Health Innovations for Stroke Care

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Association Between Primary Care Practice Telehealth Use and Acute Care Visits for Ambulatory Care-Sensitive Conditions During COVID-19

IMPORTANCE

During the COVID-19 pandemic, many primary care practices adopted telehealth in place of in-person care to preserve access to care for patients with acute and chronic conditions. The extent to which this change was associated with their rates of acute care visits (ie, emergency department visits and hospitalizations) for these conditions is unknown.

OBJECTIVE

To examine whether a primary care practice's level of telehealth use is associated with a change in their rate of acute care visits for ambulatory care-sensitive conditions (ACSC visits).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis used a difference-in-differences study design to analyze insurance claims data from 4038 Michigan primary care practices from January 1, 2019, to September 30, 2020.

EXPOSURES

Low, medium, or high tertile of practice-level telehealth use based on the rate of telehealth visits from March 1 to August 31, 2020, compared with prepandemic visit volumes.

MAIN OUTCOMES AND MEASURES

Risk-adjusted ACSC visit rates before (June to September 2019) and after (June to September 2020) the start of the COVID-19 pandemic, reported as an annualized average marginal effect. The study examined overall, acute, and chronic ACSC visits separately and controlled for practice size, in-person visit volume, zip code-level attributes, and patient characteristics.

RESULTS

A total of nearly 1.5 million beneficiaries (53% female; mean [SD] age, 40 [22] years) were attributed to 4038 primary care practices. Compared with 2019 visit volumes, median telehealth use was 0.4% for the low telehealth tertile, 14.7% for the medium telehealth tertile, and 39.0% for the high telehealth tertile. The number of ACSC visits decreased in all tertiles, with adjusted rates changing from 24.3 to 14.9 per 1000 patients per year (low), 23.9 to 15.3 per 1000 patients per year (medium), and 27.5 to 20.2 per 1000 patients per year (high). In difference-in-differences analysis, high telehealth use was associated with a higher ACSC visit rate (2.10 more visits per 1000 patients per year; 95% CI, 0.22-3.97) compared with low telehealth practices; practices in the middle tertile did not differ significantly from the low tertile. No difference was found in ACSC visits across tertiles when acute and chronic ACSC visits were examined separately.

CONCLUSIONS AND RELEVANCE

In this cohort study that used a difference-in-differences analysis, the association between practice-level telehealth use and ACSC visits was mixed. High telehealth use was associated with a slightly higher overall ACSC visit rate than low telehealth practices. The association of telehealth with downstream care use should be closely monitored going forward.

A Systematic Review of the Effectiveness of Telemedicine in Reproductive and Neonatal Health in Rural and Low-Income Areas in India

A systematic review of four relevant databases for articles about the use of telemedicine to expand access to neonatal and reproductive health in rural India was conducted. The objective of this review was to identify initiatives with evidence for potential public health benefits through large-scale implementation. Of 3,098 records from the initial search, 1,415 records were selected for further review after removing duplicates. Eight reports that met the eligibility and inclusion criteria were included in the final review. Selected studies included two types of interventions, direct telemedicine interventions with patients and indirect telemedicine interventions through frontline health care workers. Among studies involving direct telemedicine interventions, 22.4% of the collective health and knowledge outcomes (n = 49) showed statistically significant improvement in the intervention group, whereas 38.0% of the collective health and knowledge outcomes (n = 50) in the studies involving indirect telemedicine intervention showed statistically significant improvement. This systematic review suggested that the use of telemedicine interventions may have a statistically significant effect through educational impacts. There were certain limitations around the use of technology and training that may have undermined the effects of some of the outcomes. This systematic review did not receive any funding.

Comparison of smartphone application-based visual acuity with traditional visual acuity chart for use in tele-ophthalmology

PURPOSE:

The aim of this study was to compare the visual acuity (VA) by smartphone-based applications – EyeChart and the Peek Acuity to the standard Snellen chart to explore the possibility of using them as an alternative in tele-ophthalmology in the current COVID-19 pandemic.

MATERIALS AND METHODS:

An analytical type of observational study was done on 360 eyes of 184 patients above 18 years of age. Patients with VA <6/60 and gross ocular pathology were excluded from the study. VA measured by these three methods was converted to logMAR scale for ease of statistical analysis. One-way analysis of variance with post Tukey HSD was used to compare the VA measured by these three methods.

RESULTS:

There was no statistically significant difference between VA measured using the smartphone-based apps (EyeChart and Peek Acuity) and the Snellen chart (F = 2.5411, P = 0.7925) in 360 eyes assessed. VA measured by Peek Acuity (P = 0.5225) was more comparable to Snellen chart than EyeChart (P = 0.4730). Intraclass correlation coefficient (ICC) demonstrated a strong positive correlation for EyeChart (ICC: 0.982, P < 0.001) and Peek Acuity (ICC: 0.980, P < 0.001) with Snellen chart. A Bland–Altman difference plot showed good limits of agreement for both EyeChart and Peek Acuity with Snellen chart. In subgroup analysis, VA measured by Peek Acuity was not statistically different from Snellen in any subgroups, but in EyeChart, it was statistically different in emmetropes.

CONCLUSION:

VA measured by smartphone apps (EyeChart and Peek Acuity) was comparable with traditional Snellen chart and can be used as an effective, reliable, and feasible alternative to assess VA in tele-ophthalmology.

OUP accepted manuscript

Background

Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care.

Aim

The IBD Summit was held in partnership with Crohn’s & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada.

Results

A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries.

Conclusions

Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Integration of Artificial Intelligence, Blockchain, and Wearable Technology for Chronic Disease Management: A New Paradigm in Smart Healthcare

Chronic diseases are a growing concern worldwide, with nearly 25% of adults suffering from one or more chronic health conditions, thus placing a heavy burden on individuals, families, and healthcare systems. With the advent of the "Smart Healthcare" era, a series of cutting-edge technologies has brought new experiences to the management of chronic diseases. Among them, smart wearable technology not only helps people pursue a healthier lifestyle but also provides a continuous flow of healthcare data for disease diagnosis and treatment by actively recording physiological parameters and tracking the metabolic state. However, how to organize and analyze the data to achieve the ultimate goal of improving chronic disease management, in terms of quality of life, patient outcomes, and privacy protection, is an urgent issue that needs to be addressed. Artificial intelligence (AI) can provide intelligent suggestions by analyzing a patient's physiological data from wearable devices for the diagnosis and treatment of diseases. In addition, blockchain can improve healthcare services by authorizing decentralized data sharing, protecting the privacy of users, providing data empowerment, and ensuring the reliability of data management. Integrating AI, blockchain, and wearable technology could optimize the existing chronic disease management models, with a shift from a hospital-centered model to a patient-centered one. In this paper, we conceptually demonstrate a patient-centric technical framework based on AI, blockchain, and wearable technology and further explore the application of these integrated technologies in chronic disease management. Finally, the shortcomings of this new paradigm and future research directions are also discussed.

Effect of an Educational Nursing Intervention on the Mental Adjustment of Patients with Chronic Arterial Hypertension: An Interventional Study

The objective of this analytical and interventional prospective quantitative study was to assess the effect of an educational intervention performed by nurses for mental adjustment to chronic disease in patients with hypertension. A convenience sample was studied, composed of 329 participants with chronic hypertension, followed in a primary healthcare unit in the Central Region of Portugal. Data collection was carried out by applying the Mental Adjustment to Disease Scale (MADS) before and 1 month after the educational nursing intervention between September 2017 and February 2018. Prior to the application of the educational intervention, 43.5% of the participants were classified as "unadjusted" in at least one of the subscales of MADS. After the educational intervention, 21.3% of the participants classified as "unadjusted" became "adjusted" in all MADS subscales. The success rate of the intervention varied from 26.9% (in the fatalism subscale) to 44.6% (for the anxious concern subscale). Participants were more likely to be mentally "unadjusted" to hypertension if they lived with other family members, had an active professional situation before the diagnosis of hypertension, still had an active professional situation now, were under 65 years old, had a shorter time to diagnosis (1-2 years), and measured blood pressure less regularly. The educational intervention performed by nurses is relevant for the mental adjustment of hypertensive patients, contributing to increased knowledge, as well as improvement in preventive and self-care practices, facilitating the experience of the health/disease transition process.

A Digital Health Platform for Integrated and Proactive Patient-Centered Multimorbidity Self-management and Care (ProACT): Protocol for an Action Research Proof-of-Concept Trial

Background

Multimorbidity is defined as the presence of two or more chronic diseases and associated comorbidities. There is a need to improve best practices around the provision of well-coordinated, person-centered care for persons with multimorbidities. Present health systems across the European Union (EU) focus on supporting a single-disease framework of care; the primary challenge is to create a patient-centric, integrated care ecosystem to understand and manage multimorbidity. ProACT is a large-scale project funded by the European Commission under the Horizon 2020 programme, that involved the design, development, and evaluation of a digital health platform to improve and advance home-based integrated care, and supported self-management, for older adults (aged ≥65 years) living with multimorbidity.

Objective

This paper describes the trial implementation protocol of a proof-of-concept digital health platform (ProACT) in 2 EU member states (Ireland and Belgium) to support older persons with multimorbidities self-managing at home, supported by their care network (CN).

Methods

Research was conducted across 2 EU member states, Ireland and Belgium. A 12-month action research trial design, divided into 3 evaluation cycles and lasting 3 months each, with a reflective redesign and development phase of 1 month after cycles 1 and 2 was conducted. Participants were 120 (60/120, 50% in Ireland and 60/120, 50% in Belgium) older persons with multimorbidities diagnosed with two or more of the following chronic conditions: diabetes, chronic obstructive pulmonary disease, chronic heart failure, and cardiovascular diseases. With permission from persons with multimorbidities, members of their CN were invited to participate in the study. Persons with multimorbidities were provided with ProACT technologies (tablet, devices, or sensors) to support them in self-managing their conditions. CN members also received access to an app to remotely support their persons with multimorbidity. Qualitative and quantitative feedback and evaluation data from persons with multimorbidity and CN participants were collected across four time points: baseline (T1), at the end of each 3-month action research cycle (T2 and T3), and in a final posttrial interview (T4). Thematic analysis was used to analyze the qualitative interview data. Quantitative data were analyzed via platform use statistics (to assess engagement) and standardized questionnaires (using descriptive and inferential statistics). This study is approved by the ethics committees of Ireland and Belgium.

Results

The trial implementation phase for this 44-month (2016-2019) funded study was April 2018 to June 2019. The trial outcomes are at various stages of publication since 2021.

Conclusions

ProACT aims to co-design and develop a digital intervention with persons with multimorbidities and their CN, incorporating clinical guidelines with the state of the art in human-computer interaction, behavioral science, health psychology, and data analytic methods to deliver a digital health platform to advance self-management of multimorbidity at home, as part of a proactive, integrated model of supported person-centered care.

International Registered Report Identifier (IRRID)

RR1-10.2196/22125

Telemedicine in cystic fibrosis

Cystic Fibrosis (CF) requires lifetime multidisciplinary care to manage both pulmonary and extra pulmonary manifestations. The median age of survival for people with CF is rising and the number of adults with CF is expected to increase dramatically over the coming years. People with CF have better outcomes when managed in specialty centers, however access can be limited. Telemedicine and technology-based care solutions may help to overcome barriers to availability and improve access. This review outlines the use of telehealth for CF management. Telehealth has been utilized for CF across a broad variety of indications, even prior to the COVID-19 pandemic, and in general has been well accepted by patients and providers. There are a paucity of data, however, related to health outcomes, and the healthcare utilization specific to CF and its related comorbidities. Future studies are needed to address the questions of health outcomes, cost, burdens of telehealth and barriers to implementation.

Telemedicine for healthcare: Capabilities, features, barriers, and applications

Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.

THE IMPACT OF TELEMEDICINE AS A DISRUPTIVE INNOVATION ON ALLERGY/IMMUNOLOGY PRACTICE

BACKGROUND

Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children in order to improve asthma control.

OBJECTIVE

This study examines family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children.

METHODS

The Family Asthma Management System Scale (FAMSS) assesses how families manage a child's asthma. 388 caregivers completed the FAMSS at baseline. Asthma outcomes were assessed at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids required, and caregiver health-related quality of life (Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ)). Multiple regression models assessed the relationship between the FAMSS Total Score, FAMSS subscales, and asthma outcomes.

RESULTS

Higher FAMSS Total scores were associated with fewer courses of oral corticosteroids required (b=-0.23, p<0.01) and higher PACQLQ scores (b=0.07, p<0.05). At baseline, higher Integration subscale scores (b=-0.19, p<0.05) were associated with fewer courses of oral corticosteroids required, and higher Family Response scores were associate with higher PACQLQ scores (b=0.06, p<0.05). However, higher Collaboration scores were associated with lower PACQLQ at baseline (b=-0.06, p<0.05) and 6 months (b=-0.07, p<0.05).

CONCLUSION

Among this population of low-income minority preschool children, understanding how a family manages their child's asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of oral corticosteroids.

COVID-19 Case Surge and Telemedicine Utilization in a Tertiary Hospital in Korea

Background: Faced with the coronavirus disease 2019 (COVID-19) pandemic, Korea has allowed telemedicine use for a limited time. This study examined whether the surge in COVID-19 cases led to increased telemedicine use and the associated factors. Methods: Data from the electronic medical records of 929,753 outpatient episodes between March 4 and September 4, 2020, in a tertiary hospital in Korea were used. A comparison group was chosen by matching, adjusting for age and sex because only a small portion (1.0%) of the sample used telemedicine. The final sample comprised 57,972 episodes. Multivariable logistic regression analyses were performed to examine the association of independent variables with the dichotomous dependent variable (i.e., telemedicine visit/in-person visit). Results: The surge in confirmed COVID-19 cases led to significantly increased telemedicine use (101-300 new cases odds ratio [OR]: 3.00; 301-500 new cases OR: 5.82; and ≥501 new cases OR: 42.18; all p < 0.0001). Telemedicine use was also statistically associated with sex (female patients OR: 2.08), age ˃19 years, distance from the hospital (Incheon, Gyeonggi, region, OR: 1.30; and other regions, OR: 4.33), and the number of days from diagnosis (3-6 months OR: 1.21; 6-12 months OR: 1.56; 12-36 months OR: 1.98; and ≥36 months OR: 2.49). Medical Aid patients (OR: 0.83) were less likely to use telemedicine than those with National Health Insurance. Conclusions: Telemedicine can be effective in delivering health services during an outbreak. Policymakers and health care organizations are encouraged to use the results of this study to tailor telemedicine to meet the needs of patients.

Awareness and readiness to use telemonitoring to support diabetes care among care providers at teaching hospitals in Ethiopia: an institution-based cross-sectional study

OBJECTIVES

This survey aimed to assess the awareness and readiness of healthcare providers to use telemonitoring (TM) technologies for managing diabetes patients as well as to identify associated factors in Ethiopia.

DESIGN

An institution-based cross-sectional quantitative survey was conducted by using a pretested self-administered questionnaire from February to March 2020. Data analysis used a binary logistic regression and partial proportional odds model for factor identification.

PARTICIPANTS

Randomly selected 423 study physicians and nurses.

SETTING

This study was conducted at the University of Gondar and Tibebe Ghion specialised teaching referral hospitals.

OUTCOME MEASURES

Awareness and readiness towards TM in diabetes care.

RESULT

Out of 406 healthcare providers (69.7%, n=283 nurses and 30.3%, n=123 physicians) who completed the survey, 345 (38.7%) heard about TM, when it came to readiness, 321 (25.1%) and 121 (65.5%) of respondents had average and low readiness towards TM, respectively. The result of regression analysis shows that awareness towards TM was higher among respondents who had access to a computer (adjusted OR (AOR): 2.8 (95% CI 1.1 to 7.1)), computer-related training (AOR: 4.6 (95% CI 1.63 to 12.95)) and those who had the experience of supporting patients through digital tools (AOR: 1.7 (95% CI 1.0 to 2.8)). Self-perceived innovators and those who had access to a computer, computer-related training and favourable attitude towards TM had significantly higher readiness to use TM.

CONCLUSION

The findings of this survey revealed low awareness and readiness of participant's towards TM. However, this study suggests the need of improving participant's attitudes, access to smartphones and computers and technical skills to fill this gap.

Health management via telemedicine: Learning from the COVID-19 experience

At the onset of the COVID-19 (coronavirus disease 2019) pandemic, telemedicine was rapidly implemented to protect patients and healthcare providers from infection. It is unlikely that care delivery will fully return to the pre-COVID form. Telemedicine offers many opportunities to improve care efficiency, accessibility, and patient outcomes, but many challenges exist related to technology interoperability, the digital divide, and usability. We propose that telemedicine evolve to support continuity of care throughout the patient journey, including multidisciplinary care teams and the seamless integration of data into the clinical workflow to support a learning healthcare system. Importantly, evidence is needed to support this paradigm shift in care delivery to ensure the quality and efficacy of care delivered via telemedicine. Here, we highlight gaps and opportunities that need to be addressed by the biomedical informatics community to move forward with safe and effective healthcare delivery via telemedicine.

Multiple Sclerosis Progression Discussion Tool Usability and Usefulness in Clinical Practice: Cross-sectional, Web-Based Survey

Background

A digital tool, Multiple Sclerosis Progression Discussion Tool (MSProDiscuss), was developed to facilitate discussions between health care professionals (HCPs) and patients in evaluating early, subtle signs of multiple sclerosis (MS) disease progression.

Objective

The aim of this study is to report the findings on the usability and usefulness of MSProDiscuss in a real-world clinical setting.

Methods

In this cross-sectional, web-based survey, HCPs across 34 countries completed an initial individual questionnaire (comprising 7 questions on comprehensibility, usability, and usefulness after using MSProDiscuss during each patient consultation) and a final questionnaire (comprising 13 questions on comprehensibility, usability, usefulness, and integration and adoption into clinical practice to capture the HCPs’ overall experience of using the tool). The responses were provided on a 5-point Likert scale. All analyses were descriptive, and no statistical comparisons were made.

Results

In total, 301 HCPs tested the tool in 6974 people with MS, of whom 77% (5370/6974) had relapsing-remitting MS, including those suspected to be transitioning to secondary progressive MS. The time taken to complete MSProDiscuss was reported to be in the range of 1 to 4 minutes in 97.3% (6786/6974; initial) to 98.2% (269/274; final) of the cases. In 93.54% (6524/6974; initial) to 97.1% (266/274; final) of the cases, the HCPs agreed (4 or 5 on the Likert scale) that patients were able to comprehend the questions in the tool. The HCPs were willing to use the tool again in the same patient, 90.47% (6310/6974; initial) of the cases. The HCPs reported MSProDiscuss to be useful in discussing MS symptoms and their impact on daily activities (6121/6974, 87.76% initial and 252/274, 92% final) and cognitive function (5482/6974, 78.61% initial and 271/274, 79.2% final), as well as in discussing progression in general (6102/6974, 87.49% initial and 246/274, 89.8% final). While completing the final questionnaire, 94.9% (260/274) of the HCPs agreed that the questions were similar to those asked in regular consultation, and the tool helped to better understand the impact of MS symptoms on daily activities (249/274, 90.9%) and cognitive function (220/274, 80.3%). Overall, 92% (252/274) of the HCPs reported that they would recommend MSProDiscuss to a colleague, and 85.8% (235/274) were willing to integrate it into their clinical practice.

Conclusions

MSProDiscuss is a usable and useful tool to facilitate a physician-patient discussion on MS disease progression in daily clinical practice. Most of the HCPs agreed that the tool is easy to use and were willing to integrate MSProDiscuss into their daily clinical practice.

The Determinants of Telehealth Provision: Empirical Evidence from OECD Countries

Health services provided through the telecommunications system aim to improve the population’s health and well-being. This research aims to explore what digital, economic, and health factors are associated with the provision of telehealth services, especially in ageing communities. Applying Organization for Economic Cooperation and Development (OECD) countries’ experiences, this research tries to construct a logistic regression model between adopting a telehealth system or not, a binary outcome variable, and a group of potentially explanatory variables. Estimation results showed that there were thresholds for telehealth provision: The demand for telehealth service usually began when the provision of telecommunication accessibility reached 50%, the proportion of elders exceeded 10%, or the proportion of health spending occupied more than 3–5% of the gross domestic product (GDP); the slope of each variable seemed to correspond with an increase in demand for such a provision. A growing number of individuals in OECD countries are now readily served by telehealth systems under the COVID-19 pandemic. These findings could be regarded as a model for other countries for implementing the necessary infrastructure early on when any of these parameters reaches its threshold. Moreover, telehealth applied in developing countries could be elevated for wider populations to access basic health services and for the remote delivery of health care. A rational decision could be made to appropriately use additional resources in telehealth provision. With accessible e-health services, the population’s health could be improved, which in turn would possibly increase productivity and social welfare.

Rural use of health service and telemedicine during COVID-19: The role of access and eHealth literacy

The COVID-19 pandemic has driven a greater reliance on telemedicine, yet rural access, use, and satisfaction with telemedicine and the role of eHealth literacy are unknown. Using a cross-sectional design, 279 (70.6% female) western rural Canadians completed an online survey. The majority of participants reported access to telemedicine, but nearly 1/5 lacked access to online or virtual mental health services. The majority of participants had used health care services following the declared COVID-19 pandemic in North America, and just under half had used telemedicine. Telemedicine satisfaction scores were higher among participants who had used video (M = 4.18) compared to those who used phone alone (M = 3.79) (p = 0.031). Telemedicine satisfaction and eHealth literacy were correlated (r = 0.26, p = 0.005). Participants did not want telemedicine to replace in-person consultations. Telemedicine practice requires that rural residents have the resources, ability and willingness to engage with remote care.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Understanding factors critical to the implementation of ehealth in chronic disease management: a realist review protocol

INTRODUCTION

Canadians are living longer, many with multiple chronic conditions. This population of older, frail Canadians continues to grow in size as do concurrent demands for community-based, outpatient and ambulatory models of care. Ideally, a multifaceted, proactive, planned and integrated care model includes ehealth. Although several factors are known to facilitate the implementation of ehealth in chronic disease management (CDM), for example, adequate support, usability, alignment of programme objectives, there is a growing body of inconclusive evidence on what is critical for implementation. We aim to achieve a fulsome understanding of factors critical to implementation by conducting a realist review-an approach suitable for understanding complex interventions. Our proposed review will identify factors critical to the implementation of ehealth in CDM (heart failure, chronic obstructive pulmonary disease, chronic kidney disease and/or diabetes (type 1 or 2)) without limitations to care setting, language, publication year or geography. Findings will be presented in configurations of contexts, mechanisms and outcomes (CMOs).

METHODS AND ANALYSIS

A search strategy will be iteratively developed based on the concepts of 'implementation' and 'adoption' of 'ehealth' interventions used within 'CDM' to identify the peer-reviewed and grey literature published before 31 March 2021 from five databases (Medline, Embase, Cochrane, CINAHL and PsychInfo) on ehealth interventions actively involving a healthcare provider for CDM among adults. Data extraction and synthesis will be guided by Realist and Meta-review Evidence Synthesis: Evolving Standards (RAMESES) guidelines informing core concepts of CMOs, and a study output will include a middle-range-theory describing the implementation of ehealth in CDM.

ETHICS AND DISSEMINATION

Findings will be published in an open-access peer-reviewed journal and presented at relevant conferences. A multistakeholder (patients, caregivers, healthcare providers and practitioners, decision-makers and policy-makers) perspective will be used in our dissemination approach. No formal ethics approval is required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208275.