Patient Reaction to Telemedicine for Clinical Management of Hepatitis C Virus Integrated into an Opioid Treatment Program

Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial

Importance

Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers.

Objective

To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral.

Design, Setting, and Participants

Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023.

Intervention

Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312).

Main Outcomes and Measures

The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis.

Results

Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high.

Conclusions and Relevance

Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections.

Trial Registration

ClinicalTrials.gov Identifier: NCT02933970.

Bridge the gap caused by public health crises: medical humanization and communication skills build a psychological bond that satisfies patients

BACKGROUND

Patient satisfaction is an important outcome domain of patient-centered care. Medical humanization follows the patient-centered principle and provides a more holistic view to treat patients. The COVID-19 pandemic posed significant barriers to maintaining medical humanization. However, empirical study on the relationship between medical humanization and patient satisfaction is clearly absent.

OBJECTIVES

We examined the mediation effects of communication on the relationship between medical humanization and patient satisfaction when faced with a huge public health crisis like the COVID-19 pandemic, and the moderation effect of medical institutional trust on the mediation models.

METHODS

A cross-sectional survey study was performed. A final sample size of 1445 patients was surveyed on medical humanization, communication, patient satisfaction and medical institutional trust.

RESULTS

All correlations were significantly positive across the main variables (r = 0.35-0.67, p < 0.001 for all) except for medical institutional trust, which was negatively correlated with the medical humanization (r=-0.14, p < 0.001). Moderated mediation analysis showed that the indirect effect of medical humanization on patient satisfaction through communication was significant (b = 0.22, 95% CI: 0.18 ~ 0.25). Medical institutional trust significantly moderated the effect of medical humanization on patient satisfaction (b=-0.09, p < 0.001) and the effect of medical humanization on communication (b= -0.14, p < 0.001).

CONCLUSION

Medical humanization positively influence patient satisfaction, communication mediated the association between medical humanization and patient satisfaction, and medical institutional trust negatively moderated the effects of medical humanization on patient satisfaction and communication. These findings suggest that humanistic communication contributes to patient satisfaction in the face of a huge public health crisis, and patients' evaluation of satisfaction is also regulated by rational cognition.

Facilitated telemedicine for hepatitis C virus: Addressing challenges for improving health and life for people with opioid use disorder

BACKGROUND

People who use drugs (PWUD) frequently delay or avoid obtaining medical care in traditional healthcare settings. Through a randomized controlled trial, we investigated facilitated telemedicine for hepatitis C virus (HCV) integrated into opioid treatment programmes. We sought to understand the experiences and meanings of facilitated telemedicine and an HCV cure among PWUD.

METHODS

We utilized purposive sampling to interview 25 participants, 6-40 months after achieving an HCV cure. We interpreted and explicated common meanings of participants' experiences of an HCV cure obtained through facilitated telemedicine.

RESULTS

Participants embraced facilitated telemedicine integrated into opioid treatment programmes as patient-centred care delivered in 'safe spaces' (Theme 1). Participants elucidated their experiences of substance use and HCV while committing to treatment for both entities. Facilitated telemedicine integrated into opioid treatment programmes enabled participants to avoid stigma encountered in conventional healthcare settings (Theme 2). Participants conveyed facing negative perceptions of HCV and substance use disorder. Improved self-awareness, acquired through HCV and substance use treatment, enabled participants to develop strategies to address shame and stigma (Theme 3). An HCV cure, considered by PWUD as a victory over a lethal infectious disease, promotes self-confidence, enabling participants to improve their health and lives (Theme 4).

CONCLUSIONS

Integrating facilitated telemedicine into opioid treatment programmes addresses several healthcare barriers for PWUD. Similarly, obtaining an HCV cure increases their self-confidence, permissive to positive lifestyle changes and mitigating the negative consequences of substance use.

PATIENT AND PUBLIC CONTRIBUTION

In this study of patient involvement, we interviewed patient-participants to understand the meaning of an HCV cure through facilitated telemedicine. Participants from a facilitated telemedicine pilot study provided essential input on the design and outcomes of a randomized controlled trial. Pilot study participants endorsed facilitated telemedicine in a testimonial video. They attended site initiation meetings to guide trial implementation. A Patient Advisory Committee (PAC) ensured that patient participants were active members of the research team. The PAC represented patients' voices through feedback on study procedures. A Sustainability Committee supported public involvement in the research process, including educational opportunities, feedback on implementation, and future sustainability considerations.

Scaling and Sustaining Facilitated Telemedicine to Expand Treatment Access Among Underserved Populations: A Qualitative Study

Background: Opioid treatment programs are an essential component of the management of opioid use disorder (OUD). They have also been proposed as "medical homes" to expand health care access for underserved populations. We utilized telemedicine as a method to increase access for hepatitis C virus (HCV) care among people with OUD. Methods: We interviewed 30 staff and 15 administrators regarding the integration of facilitated telemedicine for HCV into opioid treatment programs. Participants provided feedback and insight for sustaining and scaling facilitated telemedicine for people with OUD. We utilized hermeneutic phenomenology to develop themes related to telemedicine sustainability in opioid treatment programs. Results: Three themes emerged on sustaining the facilitated telemedicine model: (1) Telemedicine as a Technical Innovation in Opioid Treatment Programs, (2) Technology Transcending Space and Time, and (3) COVID-19 Disrupting the Status Quo. Participants identified skilled staff, ongoing training, technology infrastructure and support, and an effective marketing campaign as key to maintaining the facilitated telemedicine model. Participants highlighted the study-supported case manager's role in managing the technology to transcend temporal and geographical challenges for HCV treatment access for people with OUD. COVID-19 fueled changes in health care delivery, including facilitated telemedicine, to expand the opioid treatment program's mission as a medical home for people with OUD. Conclusions: Opioid treatment programs can sustain facilitated telemedicine to increase health care access for underserved populations. COVID-19-induced disruptions promoted innovation and policy changes recognizing telemedicine's role in expanding health care access to underserved populations. ClinicalTrials.gov Identifier: NCT02933970.

Accessing Care During the COVID-19 Pandemic Using Telemedicine: Perspectives From People With HIV

The COVID-19 pandemic has resulted in a steep increase in telemedicine implementation and use. Data are lacking on telemedicine use in marginalized and underserved groups including people with HIV (PWH). The Ryan White HIV/AIDS Program (RWHAP) is the largest single provider of HIV care in the United States (U.S.) and the southern part of the country remains the epicenter of the HIV epidemic. This study recruited PWH from RWHAP clinics across South Texas. To ascertain their perspectives on utilizing telemedicine for HIV care during the COVID-19 pandemic, a survey instrument derived from validated instruments was used. Descriptive statistics were used for client characteristics, quality of telemedicine care, and COVID-19 impact. Wilcoxon Rank Sum and Kruskal-Wallis tests were assessed associations of telemedicine care quality and COVID-19 impact between client groups. Among 246 eligible PWH, 122 clients completed the survey with a response rate of 50%. Clients were predominantly Hispanic males. Significant differences in perception of telemedicine care and the impact of COVID-19 by gender, age, language, and race/ethnicity were observed. Older PWHIV used telemedicine more than younger clients (p = .01). English speakers indicated more impact of the COVID-19 pandemic on daily life than Spanish speakers (p = .02). Worry about the pandemic was most evident among non-Hispanic Black and Hispanic PWH (p = .03). Overall, telemedicine was found to be a favorable and acceptable mechanism of HIV care delivery by PWH in a Southern state during the COVID-19 pandemic.

Engaging people who use drugs in clinical research: integrating facilitated telemedicine for HCV into substance use treatment

BACKGROUND

People who use drugs (PWUD) have difficulty participating in clinical research. We evaluated approaches to engage PWUD in clinical research, using facilitated telemedicine for hepatitis C virus (HCV) care as an example.

METHODS

We analyzed stakeholder interview transcripts and study-related data (i.e., progress reports, meeting minutes) from interrelated studies to understand engagement experiences at the patient, site, and organizational levels. Stakeholders include patient-participants, opioid treatment program (OTP) staff and administrators, and research team members involved in HCV management through facilitated telemedicine integrated into OTPs.

RESULTS

Three themes emerged. Initially, the research team sought understanding of the unique culture and community of each OTP (Theme 1). The team built trusting relationships through education, communication, and feedback (Theme 2). Finally, the research team enhanced collaborative care and incorporated the patients' voice to improve health outcomes (Theme 3). Patient-participants and OTP staff endorsed the integrated HCV care approach. Engagement practices are summarized as the CREATE framework (C = culture, R = respect, E = educate, A = advantage, T = trust, E = endorse).

CONCLUSIONS

PWUD engagement in clinical research is maximized by building trusting relationships with open communication channels. Understanding the community, demonstrating respect, and augmenting knowledge are foundational for engaging PWUD in clinical research. These practices are transferable to engagement of PWUD in clinical research broadly.

A randomized controlled trial for a peer-facilitated telemedicine hepatitis c treatment intervention for people who use drugs in rural communities: study protocol for the "peer tele-HCV" study

BACKGROUND

Hepatitis C virus (HCV) transmission is primarily driven by injection drug use, and acute HCV infection rates are increased in rural communities with substantial barriers to care. Treatment of HCV in persons who use drugs (PWUD) is cost effective, decreases high risk behaviors and HCV transmission, and achieves high rates of treatment completion and sustained viral response. Adapting HCV care delivery to utilize peer support specialists, telemedicine technology, and streamlined testing and treatment strategies can better reach rural populations living with HCV.

METHODS

This is an open label, two-arm, non-blinded, randomized controlled trial designed to test the superiority of peer-facilitated and streamlined telemedicine HCV care (peer tele-HCV) compared to enhanced usual care (EUC) among PWUD in rural Oregon. In the intervention arm, peers conduct HCV screening in the community, facilitate pretreatment evaluation and linkage to telemedicine hepatitis C treatment providers, and support participants in HCV medication adherence. For participants assigned to EUC, peers facilitate pretreatment evaluation and referral to community-based treatment providers. The primary outcome is sustained virologic response at 12 weeks post treatment (SVR12). Secondary outcomes include: (1) HCV treatment initiation, (2) HCV treatment completion, (3) engagement with harm reduction resources, (4) rates of substance use, and (5) engagement in addiction treatment resources. The primary and secondary outcomes are analyzed using intention-to-treat (ITT) comparisons between telemedicine and EUC. A qualitative analysis will assess patient, peer, and clinician experiences of peer-facilitated telemedicine hepatitis C treatment.

DISCUSSION

This study uses a novel peer-based telemedicine delivery model with streamlined testing protocols to improve access to HCV treatment in rural communities with high rates of injection drug use and ongoing disease transmission. We hypothesize that the peer tele-HCV model will increase treatment initiation, treatment completion, SVR12 rates, and engagement with harm reduction services compared to EUC. Trial registration This trial has been registered with ClinicalTrials.gov (clinicaltrials.gov NCT04798521).

A review of questionnaires used for the assessment of telemedicine

INTRODUCTION

Telemedicine is the exchange of medical information from one site to another via electronic communications with the goal of improving a patient's clinical health status. Prior studies have identified the absence of a standardized assessment tool for evaluating telemedicine encounters. This study aims to collect and to analyze questionnaires used for the assessment of audiovisual telemedicine encounters from a patient perspective and aims to identify reasons driving the use of self-developed questionnaires.

METHODS

We conducted a systematic search in PubMed for studies that used survey questionnaires to assess synchronous audiovisual telemedicine encounters from 2016 to 2021. We categorized questionnaires used into validated and non-validated types, and for each of them, collected questions, response format, author, year, specialty, and country of publication.

RESULTS AND DISCUSSION

We analyzed a total of 71 articles. We found that only 16 studies used three validated questionnaires. The remaining 55 studies used non-validated questionnaires. Non-validated questionnaires had a high variability in length and used Likert scales, binary responses, multiple choice, and open-ended answers. We found only eight studies in which the authors gave a reason for resorting to designing their own questionnaires. This review reveals insufficient standardized survey questionnaires to be used for the assessment of audiovisual telemedicine encounters. Future research initiatives should focus on developing a standardized and validated instrument well accepted by researchers.

High Satisfaction with Patient-Centered Telemedicine for Hepatitis C Virus Delivered to Substance Users: A Mixed-Methods Study

Background: While telemedicine may increase health care access for vulnerable populations, data are limited on whether people with opioid use disorder (PWOUD) are satisfied with telemedicine. We assessed PWOUD satisfaction with telemedicine and identified factors that increase telemedicine satisfaction. Methods: We conducted a mixed-methods study among hepatitis C virus (HCV)-infected persons enrolled at 12 opioid treatment programs (OTPs) throughout New York State. Participants successfully completed HCV treatment either through telemedicine integrated into OTPs (N = 238) or through offsite referral (N = 106). We evaluated Patient Satisfaction Questionnaire (PSQ) response scores at the initial and final health care encounters and subsequently interviewed telemedicine study participants (N = 25) to assess their experiences with telemedicine. Results: All participants (N = 344) successfully completed HCV treatment. We observed no differences in PSQ scores between telemedicine and in-person encounters (98.3% and 98.7% of telemedicine participants provided PSQ scores of satisfied or highly satisfied at each timepoint, respectively). Study participants indicated that attributes associated with high telemedicine encounter satisfaction included: (1) communicating study information, (2) gaining trust, and (3) delivering patient-centered care. Participants weighted "General Satisfaction" and "Time Spent with Doctor" higher than "Accessibility and Convenience," and female participants were significantly more satisfied than males. Satisfaction with health care delivery among all participants increased significantly comparing timepoints. Conclusions: Participants were highly satisfied with HCV telemedicine encounters equivalent to in-person encounters. Communication augments trust facilitating delivery of patient-centered care through telemedicine. Participants value empathy and trust with providers over accessibility and convenience. In summary, PWOUD are highly satisfied with the facilitated telemedicine model and value empathetic and trusting providers. ClinicalTrials.gov Identifier: NCT02933970.

Analysing breast cancer survivors’ acceptance profiles for using an electronic pillbox connected to a smartphone application using Seintinelles, a French community-based research tool

Introduction: Up to 50% of breast cancer (BC) survivors discontinue their adjuvant endocrine therapy (AET) before the recommended 5 years, raising the issue of medication non-adherence. eHealth technologies have the potential to support patients to enhance their medication adherence and may offer an effective way to complement the healthcare. In order for eHealth technologies to be successfully implemented into the healthcare system, end-users need to be willing and accepting to use these eHealth technologies.

Aim: This study aims to evaluate the current usability of eHealth technologiesin and to identify differences in BC SURVIVORS BC survivors accepting a medication adherence enhancing eHealth technology to support their AET to BC survivors that do not accept such a medication adherence enhancing eHealth technology.

Methods: This study was conducted in 2020 including volunteering BC survivors belonging to the Seintinelles Association. Eligible participants were women, diagnosed with BC within the last 10 years, and been exposed to, an AET. Univariable and multivariable logistic regression analyses were performed to investigate medication adherence enhancing eHealth technology acceptance profiles among BC survivors. The dependent variable was defined as acceptance of an electronic pillbox connected to a smartphone application (hereafter: medication adherence enhancing eHealth technology).

Results: Overall, 23% of the participants already use a connected device or health application on a regular basis. The mean age of the participants was 52.7 (SD 10.4) years. In total, 67% of 1268 BC survivors who participated in the survey declared that they would accept a medication adherence enhancing eHealth technology to improve their AET. BC survivors accepting a medication adherence enhancing eHealth technology for their AET, are younger (OR = 0.97, 95% CI [0.95; 0.98]), do take medication for other diseases (OR = 0.31, 95% CI [0.13; 0.68]), already use a medication adherence enhancing eHealth technology or technique (OR = 1.74, 95% CI [1.06; 2.94]) and are willing to possess or currently possess one or more connected devices or health applications (OR = 2.89, 95% CI [2.01; 4.19]).

Conclusion: Understanding acceptance profiles of BC survivors is fundamental for conceiving an effective eHealth technology enhancing AET among BC survivors. Hence, such profiling will foster the development of personalized medication adherence enhancing eHealth technology.

Virtual Behavioral Health Treatment Satisfaction and Outcomes Across Time

PURPOSE

The COVID-19 pandemic continues to have major and long-lasting impacts on health care delivery and mental health. As health care shifted to telehealth, legislation was adjusted to expand telehealth allowances, creating a unique opportunity to elucidate outcomes. The aim of this study was to assess long-term patient and clinician satisfaction and outcomes with virtual behavioral health.

METHODS

Data were obtained over 16 months from surveys to patients and clinicians receiving/providing virtual treatment. Outcomes data also were collected from medical records of adults receiving in-person and virtual behavioral health treatment. Data were summarized using descriptive statistics. Groups were compared using various chi-squared tests for categorical variables, Likert response trends over time, and conditional independence, with Wilcoxon rank-sum or Jonckheere trend test used to assess continuous variables. P-values of ≤0.05 were considered statistically significant.

RESULTS

Patients gave high ratings to virtual treatment and indicated a preference for virtual formats. Both patient and clinician preference for virtual visits increased significantly with time, and many clinicians perceived virtual services to be equally effective to in-person. Virtual programs had higher completion rates, attendance rates, and number of treatment visits, suggesting that virtual behavioral health had equivalent or better outcomes to in-person treatment and that attitudes toward telehealth changed over time.

CONCLUSIONS

If trends found in this study continue, telehealth may emerge as a preferred option long term This is important considering the increase in mental health needs associated with the COVID-19 pandemic and the eventuality that in-person restrictions ease as the pandemic subsides.

Telemedicine Patient Satisfaction Dimensions Moderated by Patient Demographics

Background: A multi-dimensional telemedicine patient satisfaction measure is utilized to provide managerial insights into where service improvements are needed and factors that impact patient service perceptions. This research explores the influence of patient demographics on telemedicine satisfaction. Four dimensions of telemedicine patient satisfaction (health benefits, patient-centered care, monetary costs, and non-monetary costs) were compared across patient gender, income, and education levels. Methods: A survey of 440 US telemedicine patients on patient satisfaction was measured with Likert scale items to create a multi-dimensional construct using the SERVQUAL model. MANOVA, ANOVA, and linear contrasts were used to examine the impact of patient demographics on telemedicine satisfaction dimensions. Results: The findings revealed that patient demographic characteristics moderated various dimensions of their telemedicine experience satisfaction. Satisfaction with telemedicine health benefits was moderated by patient gender and income levels. Patient-centered care was moderated by patient gender, income, and education levels. Satisfaction with the monetary cost of telemedicine was associated with patient gender and education level. Patient education level influenced their satisfaction with telemedicine non-monetary costs. Discussion: Notable trends include generally higher patient satisfaction for women and those with lower education levels. Patient income showed mixed trends regarding the four dimensions of patient satisfaction. Improvements in patient health literacy along with customized services may improve telemedicine patient care satisfaction and health outcomes. Conclusions: Measuring telemedicine patient satisfaction with a multi-dimensional assessment tool provides insights into how patient demographics influence perceptions of services received. The findings highlighted perceptions of telemedicine patient satisfaction dimensions that differed across patient demographics and provided insights into their overall impact on telemedicine patient satisfaction.

Innovations in education: A prospective study of storytelling narratives to enhance hepatitis C virus knowledge among substance users

BACKGROUND

Even though substance users have the highest hepatitis C virus (HCV) burden, many lack knowledge about the infection. Lack of knowledge is an important obstacle to pursuing HCV care. Although printed materials are conventionally utilized to disseminate HCV-related knowledge, narrative story-telling videos may be an alternative. Data are extremely limited, however, in the ability of storytelling videos to increase HCV knowledge among substance users. In this study, we hypothesized that a story-telling narrative video would increase substance user’s immediate and 1-month HCV-related knowledge compared to a printed format.

AIM

To assess immediate and 1-month HCV-related knowledge retention among substance users comparing education delivered via a storytelling narrative video compared to a printed format.

METHODS

We conducted a prospective matched, case-control study among substance users actively prescribed buprenorphine enrolled from two sites. The intervention site received the video and the control site, the brochure. Participants (n = 176) were matched on age, gender, and race. We obtained extensive patient and stakeholder input on the video’s design, validated the video’s content, and developed a recruitment plan to guide participant enrollment. Knowledge was assessed by administration of a 25-item instrument immediately before, immediately after, or one month after the intervention. Data were analyzed using nonparametric and generalized linear mixed-effects models.

RESULTS

We recruited a total of 176 substance users, 90 and 86 individuals, from each site, respectively. One-month follow up occurred in 92% and 94% of enrollees in the control and intervention groups, respectively. In comparison with the pre-intervention scores, immediate knowledge recall increased significantly for both the intervention (P < 0.0001) and control (P < 0.0001) groups. Multivariate modeling revealed a significant improvement in HCV-related knowledge and retention (P = 0.033) among participants who viewed the storytelling video.

CONCLUSION

Storytelling narratives emphasizing HCV education appear to be an effective method to increase HCV-related knowledge among substance users. They should become an educational cornerstone to promote HCV management among this population.

Can Telemedicine Optimize the HCV Care Cascade in People Who Use Drugs? Features of an Innovative Decentralization Model and Comparison with Other Micro-Elimination Strategies

Simple Summary

The global fight against the hepatitis C virus (HCV) involves the processes of micro-elimination of populations at risk. People who use drugs (PWUDs) represent a viral reservoir, due to the historical challenge in treating this population. In particular, the difficulties in the linkage to care of these patients, as well as low adherence to therapies and follow-up and the risk of re-infection make PWUDs a “difficult-to-treat” population. In view of this, the testing of effective management and treatment models for chronic HCV infection in PWUDs is crucial for promoting its elimination. Telemedicine could be a successful solution in the integration and decentralization of care services.

Abstract

People who use drugs (PWUDs) are a crucial population in the global fight against viral hepatitis. The difficulties in linkage to care, the low adherence to therapy, the frequent loss to follow-up and the high risk of re-infection make the eradication process of the hepatitis C virus (HCV) really hard in this viral reservoir. Several management and treatment models have been tested with the aim of optimizing the HCV care cascade in PWUDs. Models of decentralization of the care process and integration of services seem to provide the highest success rates. Giving this, telemedicine could favor the decentralization of diagnostic-therapeutic management, key for the implementation of linkage to care, reduction of waiting times, optimization of adherence and results and reduction of the costs. The purpose of this literature review is to examine the role and possible impact of telemedicine in optimizing the HCV care cascade, comparing the different care models that have shown to improve the linkage to care and therapeutic adherence in this special population.

Telemedicine in Hepatology: Current Applications and Future Directions

Telemedicine refers to the use of information and communication technologies for providing health care at a distance. Through the use of telecommunication technologies such as cell phones, computers, and other electronic devices, health care providers are able to conduct patient visits, mentor/train other providers, and monitor patients' chronic diseases remotely, potentially hundreds or thousands of miles away. Over the past 2 decades, the use of telemedicine has grown in the field of hepatology. In this review, we provide a focused primer on telemedicine and its current applications in hepatology. In particular, we discuss the use of telemedicine in the management of chronic hepatitis C, the complications of liver disease, as well as preliver transplantation evaluation and posttransplantation care. In addition, we provide a synopsis of the effect of the coronavirus disease 2019 (COVID-19) pandemic on the use of telemedicine in hepatology.

The Most Important Telemedicine Patient Satisfaction Dimension: Patient-Centered Care

Background: Telemedicine provider success requires patient satisfaction. The SERVQUAL model was used to identify the most salient telemedicine patient satisfaction dimensions. Materials and Methods: The author surveyed 440 telemedicine patients using Likert items to examine satisfaction levels. Four performance dimensions of telemedicine service were identified and examined. Factor analysis was used to validate the telemedicine performance dimensions measured, and regression analysis was used to test the effects of the service performance dimensions on telemedicine patient satisfaction. Results: The SERVQUAL model provided reliable measures of satisfaction dimensions. Four dimensions of satisfaction were identified, and patient-centered care was shown to be the most significant dimension. Patient perceptions of health benefits received from the telemedicine service were also found to impact patient satisfaction. The other two dimensions, monetary and non-monetary costs, did not have a significant effect on patient satisfaction. Discussion: Patient satisfaction was effectively measured as a multidimensional construct by using the service-marketing SERVQUAL model. The value that patients place on provider "soft skills" (i.e., bedside manner) during provider-patient interactions was demonstrated. Therefore, health care providers could develop and embrace patient-centered communication, such as having an empathetic and caring attitude, showing responsiveness to the emotional needs of the patient, and providing assurance to the patient to improve telemedicine patient satisfaction. Conclusions: The SERVQUAL model is useful to create a comprehensive, multidimensional construct for telemedicine patient satisfaction, which can lead to improved telemedicine patient satisfaction. The multidimensional approach highlights satisfaction dimensions where targeted improvements are most appropriate and, thus, can provide more focused practice guidance to providers.

Patient-centered HCV care via telemedicine for individuals on medication for opioid use disorder: Telemedicine for Evaluation, Adherence and Medication for Hepatitis C (TEAM-C)

BACKGROUND

Telemedicine has the potential to increase healthcare access especially for vulnerable populations. Telemedicine for Evaluation, Adherence, and Medication for Hepatitis C (TEAM-C) is comparing telemedicine access to specialty medical care to usual care for management of hepatitis C virus (HCV) infection among persons with opioid use disorder (PWOUD). PWOUD have the highest hepatitis C virus (HCV) prevalence and incidence, yet they infrequently receive HCV care. The study objectives are to compare access to specialty care via telemedicine to offsite specialty referral (usual care) on 1) treatment initiation, completion, and sustained virological response, 2) patient satisfaction with health care delivery, and 3) HCV reinfection after successful HCV cure.

METHODS

TEAM-C is a multi-site, non-blinded, randomized pragmatic clinical trial conducted at 12 opioid treatment programs (OTP) throughout New York State that utilizes the stepped-wedge design. The unit of randomization is the OTP with a total sample size of 624 participants. HCV-infected PWOUD were treated via telemedicine or referral. Telemedicine encounters are conducted onsite in the OTP with co-administration of direct acting antivirals for HCV with medications for opioid use disorder. The primary outcome is undetectable HCV RNA obtained 12 weeks post-treatment cessation. We also follow participants for two years to assess for reinfection.

CONCLUSIONS

The study utilizes a rigorous study design to evaluate the effectiveness and implementation of virtual treatment for HCV integrated into behavioral treatment. We demonstrate the feasibility, engagement principles and lessons learned from the initial prospective randomized trial of telemedicine targeted to a vulnerable population.

Facilitating engagement of persons with opioid use disorder in treatment for hepatitis C virus infection via telemedicine: Stories of onsite case managers

Although hepatitis C virus (HCV) infection has high prevalence and incidence in persons with opioid use disorder (PWOUD), their engagement in HCV care has been limited due to a variety of factors. In an ongoing multisite study at 12 opioid treatment programs (OTPs) throughout New York State (NYS), we have been evaluating telemedicine accompanied by onsite administration of direct acting antiviral (DAA) medications compared with usual care including offsite referral to a liver specialist for HCV management. Each site has a case manager (CM) who is responsible for all study-related activities including participant recruitment, facilitating telemedicine interactions, retention in care, and data collection. Our overall objective is to analyze CM experiences of clients' stories and events to understand how the telemedicine model facilitates HCV treatment. Hermeneutic phenomenology was used to interpret and to explicate common meanings and shared practices of the phenomena of case management, and a focus group with CMs was conducted to reinforce and expand on key themes identified from the CMs' stories. We identified three themes: (1) building trust, (2) identification of multiple competing priorities, and (3) development of personalized care approaches. Our results illustrate that trust is a fundamental pillar on which the telemedicine system can be based. Participants' experiences at the OTP can reinforce trust. Understanding the specific competing priorities and routinizing dedicated personalized approaches to overcome them are key to increasing participation in HCV care among PWOUD.

Telemedicine and decentralized hepatitis C treatment as a strategy to enhance retention in care among people attending drug treatment centres

BACKGROUND

People attending drug treatment centres have a high burden of hepatitis C virus (HCV) and face barriers to diagnosis and treatment. Dried blood spot (DBS) testing has been proposed to simplify diagnosis, but many patients remain untreated. In this retrospective study, we evaluated the reasons for non-retention in care in an intervention using on-site DBS testing and the effect of telemedicine and decentralized care compared to standard of care among people attending drug treatment centres who were lost to follow-up.

METHODS

In a first phase, retention in care, adherence to treatment, and predictive factors in the DBS testing program of patients in drug treatment centres were analyzed and compared to a cohort of patients treated at the hospital outpatient clinic. Subsequently, in a second phase we evaluated in patients lost to follow-up from drug treatment centres the efficacy of one-step testing and telemedicine linked to a decentralized dispensation of HCV treatment or standard of care.

RESULTS

Among 512 patients attending drug treatment centres, 467 (91.2%) agreed to be tested and 53.4% (237 patients/444 valid tests) tested positive (46 ± 9 years, 87.3% male) for HCV antibodies. After excluding patients negative for RNA or under surveillance, 178 patients were scheduled to meet with a specialist. Overall, 44 patients did not attend and 25 did not complete the pre-treatment evaluation. The only factor associated with retention in care was patient's knowledge of HCV infection. Treated patients attending drug treatment centres (n = 68) compared to the hospital outpatient clinic cohort (n = 135) had lower rates of treatment adherence. Among the patients who attended drug treatment centres that were lost to follow-up (n = 69), the proportion of patients who completed the program was significantly higher among those assisted by telemedicine than by standard of care (62.5% vs. 24.3%, p = 0.002).

CONCLUSION

Although there was a high participation rate in a DBS testing program in drug treatment centres, non-retention in care is a challenge. Importantly, telemedicine linked to a decentralized dispensation of HCV treatment re-engages patients and may be effective for HCV microelimination.

The most used questionnaires for evaluating telemedicine services

Background

Questionnaires are commonly used tools in telemedicine services that can help to evaluate different aspects. Selecting the ideal questionnaire for this purpose may be challenging for researchers. This study aims to review which questionnaires are used to evaluate telemedicine services in the studies, which are most common, and what aspects of telemedicine evaluation do they capture.

Methods

The PubMed database was searched in August 2020 to retrieve articles. Data extracted from the final list of articles included author/year of publication, journal of publication, type of evaluation, and evaluation questionnaire. Data were analyzed using descriptive statistics.

Results

Fifty-three articles were included in this study. The questionnaire was used for evaluating the satisfaction (49%), usability (34%), acceptance (11.5%), and implementation (2%) of telemedicine services. Among telemedicine specific questionnaires, Telehealth Usability Questionnaire (TUQ) (19%), Telemedicine Satisfaction Questionnaire (TSQ) (13%), and Service User Technology Acceptability Questionnaire (SUTAQ) (5.5%), were respectively most frequently used in the collected articles. Other most used questionnaires generally used for evaluating the users’ satisfaction, usability, and acceptance of technology were Client Satisfaction Questionnaire (CSQ) (5.5%), Questionnaire for User Interaction Satisfaction (QUIS) (5.5%), System Usability Scale (SUS) (5.5%), Patient Satisfaction Questionnaire (PSQ) (5.5%), and Technology Acceptance Model (TAM) (3.5%) respectively.

Conclusion

Employing specifically designed questionnaires or designing a new questionnaire with fewer questions and more comprehensiveness in terms of the issues studied provides a better evaluation. Attention to user needs, end-user acceptance, and implementation processes, along with users' satisfaction and usability evaluation, may optimize telemedicine efforts in the future.

Patient Centeredness in Hepatitis C Direct-Acting Antiviral Treatment Delivery to People Who Inject Drugs: A Scoping Review

Background and Objective

Patient-centered care (PCC) is crucial for value-based care. We aimed to assess PCC dimensions addressed in hepatitis C virus direct-acting antiviral treatment delivery to people who inject drugs.

Methods

We conducted a scoping review to identify the studies that described hepatitis C virus treatment delivery to people who inject drugs in the direct-acting antiviral treatment era. We analyzed the included studies against eight PCC dimensions: (1) access to care; (2) coordination and integration of care; (3) continuity and translation; (4) physical comfort; (5) information, education, and communication; (6) emotional support; (7) involvement of family and friends; and (8) respect for individual patient preferences, perceived needs, and values. Additionally, we assessed the use of patient-centered terminology and the recognition of PCC importance and its relevance to treatment outcomes.

Results

None of the identified 36 studies addressed all PCC dimensions (highest seven, lowest two). Our findings revealed that PCC dimensions are prioritized differently and addressed using different approaches and strategies. Studies that used PCC terminology referred to personalized activities, which does not imply comprehensive PCC. About one-third of the studies acknowledged the importance of patient centeredness and two-thirds recognized its relevance to treatment outcomes.

Conclusions

Our findings suggest more engagement of people who inject drugs and comprehensive involvement of their families and friends in hepatitis C virus treatment journey, decisions, and outcomes. The recognition of PCC importance and its relevance to treatment outcomes in the analyzed studies emphasizes the need for more patient-centered hepatitis C virus treatment for people who inject drugs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-020-00489-6.

A framework for patient-centered telemedicine: Application and lessons learned from vulnerable populations

Virtual technologies can facilitate clinical monitoring, clinician-patient interactions, and enhance patient-centered approaches to healthcare delivery. Telemedicine, two-way communication between a healthcare provider and a patient not in the same physical location, emphasizes patient preference and convenience by substituting the transportation of patients with information transfer. We present a framework for implementation of a comprehensive, dynamic, patient-centered telemedicine network deployed in 12 opioid treatment programs (OTP) located throughout New York State (NYS). The program aims to effectively manage hepatitis C virus (HCV) infection via telemedicine with co-administration of HCV and substance use medications. We have found that the Sociotechnical System model with emphasis on patient-centered factors provides a framework for telemedicine deployment and implementation to a vulnerable population. The issue of interoperability between the telemedicine platform and the electronic health record (EHR) system as well as clinical information retrieval for medical decision-making are challenges with implementation of a comprehensive, dynamic telemedicine system. Targeting telemedicine to a vulnerable population requires additional consideration of trust in the security and confidentiality of the telemedicine system. Our contribution is the valuable lessons learned from implementing a comprehensive, dynamic, patient-centered telemedicine system among an OTP network throughout NYS as applied to a vulnerable population that can be generalized to other difficult-to-reach populations.

The Current and Future Use of Telemedicine in Infectious Diseases Practice

PURPOSE OF REVIEW

Novel technologies, such as high-definition cameras, encryption software, electronic stethoscopes, microfluidic diagnostic systems, and widely available broadband Internet have expanded the potential for telemedicine. This narrative review presents current and future uses of telemedicine in the prevention, diagnosis, treatment, stewardship, and management of infectious disease.

RECENT FINDINGS

Beginning in the 1990s, early approaches to telemedicine in infectious disease focused largely on treatment of HIV/AIDS, hepatitis C, and tuberculosis. However, recent innovations allow for targeting of additional diseases and in increasingly remote settings. Telemedicine allows virtual visits between patients in the home and remote providers, permitting outpatient management of complex conditions, such as post-surgical site monitoring, and non-urgent infectious maladies, such as uncomplicated urinary tract infection. Remote provider education by videoconference and integrated clinical decision support tools create avenues to improve inpatient care, including antimicrobial stewardship. Technological strides from miniaturization of diagnostic tests to robotic telepresence physical exams improve access to infectious disease care in isolated and infrastructure-poor environments, from cargo ships to other resource-limited settings. Telemedicine in the field of infectious disease is rapidly expanding in clinical, technological, geographical, and human capacity. Recent innovations narrow gaps in access to care for populations traditionally underserved, stigmatized, isolated by remote geography, or lacking technological infrastructure. Current and future approaches will transform inpatient, outpatient, and remote care.