Evaluation of a French Regional Telemedicine Network Dedicated to Neurological Emergencies: A 14-Year Study

Mapping Digital Public Health Interventions Among Existing Digital Technologies and Internet-Based Interventions to Maintain and Improve Population Health in Practice: Scoping Review

BACKGROUND

The rapid progression and integration of digital technologies into public health have reshaped the global landscape of health care delivery and disease prevention. In pursuit of better population health and health care accessibility, many countries have integrated digital interventions into their health care systems, such as web-based consultations, electronic health records, and telemedicine. Despite the increasing prevalence and relevance of digital technologies in public health and their varying definitions, there has been a shortage of studies examining whether these technologies align with the established definition and core characteristics of digital public health (DiPH) interventions. Hence, the imperative need for a scoping review emerges to explore the breadth of literature dedicated to this subject.

OBJECTIVE

This scoping review aims to outline DiPH interventions from different implementation stages for health promotion, primary to tertiary prevention, including health care and disease surveillance and monitoring. In addition, we aim to map the reported intervention characteristics, including their technical features and nontechnical elements.

METHODS

Original studies or reports of DiPH intervention focused on population health were eligible for this review. PubMed, Web of Science, CENTRAL, IEEE Xplore, and the ACM Full-Text Collection were searched for relevant literature (last updated on October 5, 2022). Intervention characteristics of each identified DiPH intervention, such as target groups, level of prevention or health care, digital health functions, intervention types, and public health functions, were extracted and used to map DiPH interventions. MAXQDA 2022.7 (VERBI GmbH) was used for qualitative data analysis of such interventions' technical functions and nontechnical characteristics.

RESULTS

In total, we identified and screened 15,701 records, of which 1562 (9.94%) full texts were considered relevant and were assessed for eligibility. Finally, we included 185 (11.84%) publications, which reported 179 different DiPH interventions. Our analysis revealed a diverse landscape of interventions, with telemedical services, health apps, and electronic health records as dominant types. These interventions targeted a wide range of populations and settings, demonstrating their adaptability. The analysis highlighted the multifaceted nature of digital interventions, necessitating precise definitions and standardized terminologies for effective collaboration and evaluation.

CONCLUSIONS

Although this scoping review was able to map characteristics and technical functions among 13 intervention types in DiPH, emerging technologies such as artificial intelligence might have been underrepresented in our study. This review underscores the diversity of DiPH interventions among and within intervention groups. Moreover, it highlights the importance of precise terminology for effective planning and evaluation. This review promotes cross-disciplinary collaboration by emphasizing the need for clear definitions, distinct technological functions, and well-defined use cases. It lays the foundation for international benchmarks and comparability within DiPH systems. Further research is needed to map intervention characteristics in this still-evolving field continuously.

TRIAL REGISTRATION

PROSPERO CRD42021265562; https://tinyurl.com/43jksb3k.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33404.

Medical demography at stroke centers: Current situation in France

INTRODUCTION

Following the 2010-2014 French national stroke action plan, the number of stroke center (SC) has gradually increased in France, allowing a homogeneous coverage and access to neurovascular care in organized and territorially defined structures. However, operational difficulties within SCs have been progressively reported over the last few years. The objective of this study was to identify the medical staff shortages in SC that may contribute to these difficulties.

METHODS

A survey on the medical staffing level as of January 1, 2021 was sent to all French SC managers. Specific questions related on vacancies, need of interim medical staff, and participation in out-of-hour healthcare services.

RESULTS

Among the 139 SC managers contacted, 122 (88%) filled in the questionnaire. Analysis of the data showed that over 879 physician positions opened, 163 (18.5%) remained vacant for a mean of two years, and that in 51 SCs (41.9%), more than two positions were unfilled. In 13 of these 51 SCs, the out-of-hour healthcare services relied on less than four practitioners, defining a critical situation, and three other SCs had to close temporarily (2) or permanently (1). Moreover, 39.2% of SCs with at least one vacancy used interim physicians, for a median period of 12.5 weeks/year (IQR 5-18).

CONCLUSION

This study highlights the significant medical staff shortage in French SCs. In the absence of urgent measures, more SCs will close, jeopardizing the regional network and access to care for stroke patients.

Prospective observational study of stroke in Cayenne, Tours and Besançon: The BECATOUR study

BACKGROUND

Stroke is a major public health issue. Its epidemiology is still poorly known in French Guiana.

METHOD

We conducted a prospective observational study including 100 consecutive patients hospitalized for stroke in Cayenne (in French Guiana), and Tours and Besançon (in metropolitan France). We compared their age, medical history, cardiovascular risk factors, pre-admission Rankin score, Glasgow and NIHSS scores, usual treatments, acute phase management, type of stroke, duration of hospitalization, mechanism of stroke according to TOAST classification, NIHSS and Rankin scores at discharge, discharge treatments, and mode of discharge.

RESULTS

In French Guiana, the average age of patients was 7years lower (62 y), patients were more frequently affected by hypertension (75%) and diabetes (31%). Lacunar strokes were overrepresented (16.1%), and infarctions of cardioembolic origin were underrepresented (12%). NIHSS entry and Glasgow scores were similar between French Guiana and mainland France. Acute management was different: thrombolysis rate (9.3%) was 3 to 4 times lower, thrombectomy was not available. Fewer patients were transferred to rehabilitation centers and more patients were transferred to home hospitalization.

DISCUSSION

In Tours and Besançon, patients eligible for thrombectomy were overrepresented. This bias explains the overrepresentation of more severe infarctions and probably the overrepresentation of strokes of cardioembolic origin. Infarctions of undetermined origin were more numerous in French Guiana because patients were often discharged from hospital with an incomplete cardiological workup.

CONCLUSION

Despite some caveats, the profile of patients admitted for stroke in French Guiana is different from mainland France. The establishment of a stroke unit and an information campaign on the symptoms of stroke would allow better management.

Telehealth in trauma: A scoping review

BACKGROUND

The purpose of this scoping review was to ascertain how 'telehealth' is utilised within health care, from pre hospital to admission, discharge and post discharge, with patients who have suffered major trauma.

METHODS

A scoping review of the literature published in English since 1980 was conducted using MEDLINE, Ovid EMBASE, PsychINFO, CINAHL, Austhealth, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane library) and Web of Science MEDLINE and MEBASE to identify relevant studies.

RESULTS

We included 77 eligible studies with both randomised controlled trial and cohort design methodology. A variety of trauma was included such as traumatic brain injuries (n = 52; 67.5%), spinal cord injury (n = 14; 18.2%) and multi-trauma (n = 9; 11.7%) to both adult (n = 38) and paediatric (n = 32) participants. Telehealth is used in pre-hospital and acute-care settings (n = 11; 14.3%) to facilitate assessment, and in rehabilitation and follow-up (n = 61; 79.2%) to deliver therapy. Effects on health were reported the most (n = 46), with no negative outcomes. The feasibility of telehealth as a delivery mode was established, but coordination and technical issues are barriers to use. Overall, both patients and clinicians were satisfied using this mode of delivery.

CONCLUSION

This review demonstrates how telehealth is utilised across a spectrum of patients with traumatic injuries and to facilitate delivery of therapy, specialist consultations and assessments, with many studies reporting improvements to health. There is a paucity of high-quality rigorous research, which makes replication of findings and uptake of the intervention problematic. Future telehealth and trauma research should focus on the quality and reproducibility of telehealth interventions and the economic feasibility of using this platform to deliver trauma care.

Results of a four-year multi-channel regional program for monitoring stroke survivors in Franche-Comté, France

INTRODUCTION

Clinical monitoring of stroke survivors after hospital discharge was initiated in France in 2012 and funding for its model began in 2016. A regional program in Franche-Comté relying on various assessment methods including telehealth was initiated. The objective of this study was to describe the implementation and quality of the program.

METHODS

A retrospective observational study was conducted from 1^st January 2016 to 31^st December 2019. Patients were included if they were adults, hospitalized for stroke or transient ischemic attack in one of the six public hospitals in the region and discharged alive. There were five types of monitoring methods: physical consultation, day hospital, nurse-led phone consultation, postal mail or medical record analysis. Characteristics, method of monitoring and discharge delay were described.

RESULTS

In total, 7166 patients were identified; male gender predominated (52.9%); mean age was 72.2years. Monitoring coverage increased from 89.2% to 92% within the period. Most patients had ischemic stroke (68.5%, n=4912) and were at home at the time of monitoring (71.6%, n=5130). The main method was nurse-led phone consultations (40.8%, n=2921) followed by physical consultation (16%, n=1143). Day hospital monitoring increased (1.5% to 14.4%) while the postal mail method decreased (18.7% to 8.1%). The average delay decreased from 240.3 to 148.6days. Monitoring period of less than four months was 46.2% in 2019 and 75.3% for thrombolysis. In 2019, 99.3% of patients were being monitored at one year. Mortality decreased from 10% to 6.3%.

DISCUSSION

The program improved over time with an increase in the number of patients and reduction in delays and mortality rate.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

A systematic review of telehealth for the delivery of emergent neurosurgical care

INTRODUCTION

In 2017, the American Association of Neurological Surgeons and Congress of Neurological Surgeons published a statement in support of adopting telemedicine technologies in neurosurgery. The position statement detailed the principles for use and summarised the active efforts at the time to address barriers that limited expansion of use, such as reimbursement, liability, credentialing and patient confidentiality. The primary aim of this systematic literature review was to identify the available published literature on the application of telemedicine to neurosurgical patient care, with a specific focus on neurotrauma and emergent neurological conditions.

METHODS

This Level II systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Following removal of duplicates, 359 studies were yielded from database query. Following application of inclusion and exclusion criteria, 78 articles were identified for full-text review.

RESULTS

Full-text screening yielded a total of 11 studies for the final analysis. The study interventions took place in seven unique countries and included both developed and developing nations. Data captured spanned the years 1997 to 2019. The total cumulative number of patients who received neurosurgical telemedicine consultations captured by this review was 37,224.

DISCUSSION

This review of the literature suggests that telemedicine in emergent settings offers safe, feasible, and cost-reducing methods of increasing access to high acuity neurosurgical care and may serve to limit unnecessary inter-facility transfers. As infrastructure and regulatory guidelines continue to evolve, neurosurgical patients, both domestic and abroad, will benefit from improved access to expertise afforded by telemedicine technologies.

A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center

Background

Neurology services in rural and semi-urban part of India are very limited, due to poor infrastructure, resources, and manpower. Tele-neurology consultations at a non-urban setup can be considered as an alternative and innovative approach and have been quite successful in developed countries. Therefore, an initiative to bridge this health gap through Tele-Medicine has been taken by the Government of India.

Aim

To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Neurology consultations from the Tele-Medicine Centre, National Institute of Mental Health and Neurosciences, Bengaluru.

Methodology

We reviewed case files of such patients between December 2010 and March 2017. A total 189 collaborative tele-neurology outpatient consultations were provided through the Tele-Medicine Centre, located at a tertiary hospital-based research centre in southern India.

Results

The mean age of the patients was 39.6 (±19) years and 65.6% were aged between 19 to 60 years; 50.8% were male. The most common diagnosis was a seizure disorder in 17.5%, followed by cerebrovascular accident/stroke in 14.8%. Interestingly, 87.3% were found to benefit from tele-neurology consultations using interventions such as a change of medications in 30.1%, referral to a specialist for review in 15.8%, and further evaluation of illness and inpatient care for 7.93%.

Conclusion

This study has demonstrated the successful implementation of outpatient-based collaborative tele neurology consultation in Karnataka.

HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks

Background

The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes.

Method and findings

Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 –December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services.

Conclusions

Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.

Examining the Emergency Medical Treatment and Active Labor Act: impact on telemedicine for neurotrauma

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2)

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.

Acute telestroke in France: A systematic review

BACKGROUND

Acute telestroke is the use of telemedicine to improve acute stroke care. It has demonstrated to be a safe and effective medical practice. Since 2011, acute telestroke has been promoted by the Ministry of Health in France, and in 2018 many regions were in the process or completion of implementing telestroke. The objective of this study was to describe acute telestroke implementation in France.

METHODS

A systematic review was conducted using PubMed and ScienceDirect databases. Articles and abstracts in English and French, published between January 1st, 2000 to April 30th, 2018 were used. Studies conducted in France and that had presented an outcome evaluation of a regional acute telestroke activity were included. No meta-analysis was conducted.

RESULTS

A total of 24 studies (14 in French, 10 in English) were included, with 13 published articles (7 indexed on PubMed) and 11 abstracts. Among the 13 published articles, there were seven observational retrospective studies, one quasi-experimental before-after study, one experimental randomised controlled trial, and four medico-economic studies. All telestroke network models of care were drip-and-ship with hub and spoke organisation. The case-control studies did not show a difference with or without telemedicine. The territorial thrombolysis rate was measured in two regions, with an increase in Franche-Comté from 0.2% (2004) to 9.9% (2015), and a relative increase of 76% in Nord-Pas-de-Calais between 2009-2010 and 2012.

CONCLUSION

Implementation of acute telestroke in France had a positive clinical and public health impact but the evaluation remained limited and needs to be supported.

National survey of telemedicine education and training in medical schools in France

INTRODUCTION

Telemedicine is a remote medical practice using information communication technology (ICT), and has been increasing in France since 2009. With all new forms of medical practice, education and training (ET) is required for quality and safety. To date, implementation of telemedicine ET has not been assessed in France. The objective of this study was to describe the implementation of telemedicine ET and evaluate the knowledge, attitudes and practices (KAP) of deans and associate deans from all medical schools in France.

METHODS

A cross-sectional non-mandatory, descriptive online survey with a self-administered questionnaire was performed from 15 November to 6 December, 2017. Respondents were accessed through the 'Conférence des doyens des Facultés de médecine'.

RESULTS

There were 48 respondents with a 47.4% response rate among deans. Telemedicine ET was limited in France; 10.4% in 1st year medicine (PACES); 4% in the final 3 years of medical school (D.F.A.S.M.) and 18.8% in medical residency. Emergency medicine, dermatology, radiology, neurology and geriatrics were specialties with implemented telemedicine training during residency. Of all respondents, 90% expressed a need to increase telemedicine ET, among which 75% accepted external support. A highly positive attitude towards telemedicine practice was reflected by 60.4% of respondents, and 56.2% practiced telemedicine at least once.

DISCUSSION

This study was the first to assess national telemedicine ET implementation in France. Telemedicine was integrated into initial medical education; however, telemedicine ET remains limited despite the positive attitudes of deans and associate deans. Further research would need to be conducted on telemedicine ET implementation and KAP of medical students and residents.

A Web-Based Survey Assessing the Attitudes of Health Care Professionals in Germany Toward the Use of Telemedicine in Pregnancy Monitoring: Cross-Sectional Study

Background

The demand for fetal monitoring and constant reassurance is high in pregnant women. Consequently, pregnant women use various health apps and are more likely to visit emergency departments due to subjective but nonurgent complaints. However, electronic health (eHealth) and mobile health (mHealth) solutions are rarely used to prevent nonurgent emergency consultations. To implement modern care solutions, a better understanding of the attitudes, fears, and hopes of health care professionals toward eHealth and mHealth is needed.

Objective

The aim of this study was to investigate the attitudes of health care professionals in obstetrics toward telemedicine.

Methods

A quantitative Web-based survey on health care professionals in obstetrics in Germany was conducted. The participants included nurses, midwives, and physicians of all age groups and job positions working in hospitals that provide various levels of health care. The questionnaire comprised 24 questions about the characteristics of the study population, views about emergency consultations in obstetrics, attitude toward telemedicine, job satisfaction, and sleeping behavior.

Results

In total, 244 health care professionals participated in the Web-based survey. In general, health care professionals were skeptical (170/233, 72.9%) about the use of telemedicine in obstetrics; however, 55.8% (130/233) recognized its potential. Moreover, 72% (62/86) of physicians were optimistic in using apps for pregnancy monitoring, whereas 36.1% (47/130) of nonphysicians (P<.001) were not. Significantly, more nonphysicians rejected such developments (75/130, 57.7% rejected) compared with physicians (24/86, 28%; P<.001). We also found that obstetricians with more than 10 years of work-experience are more skeptical; however, approximately 49% (18/37) of them believed that telemedicine could reduce nonurgent emergency consultations, whereas 73.2% (106/145) of obstetricians with less than 5 years of experience (P=.01) thought otherwise. Our survey revealed a high job satisfaction and a prevalence of regular sleeping problems of 45.9% (91/198) among health care professionals in obstetrics. Surprisingly, both job satisfaction and sleeping problems were independent from the number of night shifts per month (P=.77 and P=.99, respectively). Yet, 56.6% (112/198) of the survey participants thought they would be happier with their job if they had to work fewer night shifts per month.

Conclusions

Our study reveals an ambivalent attitude toward the use of telemedicine among health care professionals in obstetrics in Germany at the moment. Efforts to promote the use of telemedicine should focus on nurses and midwives because these groups are the most skeptical. By contrast, particularly young physicians recognize the potential of apps in patient care and would like to use such technology in pregnancy monitoring.