Advancing health equity and access using telemedicine: a geospatial assessment

Effectiveness of Telehealth Versus In-Person Informed Consent: Randomized Study of Comprehension and Decision-Making

BACKGROUND

Obtaining informed consent (IC) is vital for ethically and effectively recruiting participants in research projects. However, traditional in-person IC approaches encounter notable obstacles, such as geographic barriers, transportation expenses, and literacy challenges, which can lead to delays in enrollment and increased costs. Telehealth, especially teleconsent, offers a potential way to overcome these obstacles by facilitating the IC process in a digital setting. Nonetheless, there are concerns about whether teleconsent can achieve levels of understanding and involvement that are equivalent to those of in-person IC meetings.

OBJECTIVE

This study aims to evaluate comprehension and decision-making in participants undergoing teleconsent versus traditional in-person IC. We used validated assessments to determine whether teleconsent is a viable alternative that maintains participants' understanding and decision-making abilities.

METHODS

A randomized comparative study design was used, recruiting potential participants for a parent study assessing patient experiences with patient portals. Participants were randomly assigned to 2 groups: teleconsent and in-person consent. The teleconsent group used Doxy.me software, allowing real-time interaction between researchers and participants while reviewing and electronically signing the IC documents. Recruitment involved using an institutional web-based platform to identify interested individuals, who were then contacted to assess eligibility and gather demographic information. The Decision-Making Control Instrument (DMCI) survey was used to assess the perceived voluntariness, trust, and decision self-efficacy. The Quality of Informed Consent (QuIC) was used to measure the comprehension level of the consent form. The validated Short Assessment of Health Literacy-English tool was used to measure participants' health literacy levels.

RESULTS

A total of 64 participants were enrolled in the study, with 32 in the teleconsent group and 32 in the in-person group. Of 64 participants, 32 (50%) were in the teleconsent group, 54 (84.4%) were females, 44 (68.7%) were aged 18-34 years, 50 (78.1%) were White, and 31 (48.4%) had a bachelor degree. The mean SAHL-E scores were different between the teleconsent and in-person groups (16.72, SD 1.88 vs 17.38, SD 0.95; P=.03). No significant differences were found between the average scores at baseline and follow-up for QuIC part A (P=.29), QuIC part B (P=.25), and DMCI (P=.38) within the teleconsent and in-person groups. Additionally, there were no significant differences in QuIC or DMCI between subgroups based on age, sex, and ethnicity.

CONCLUSIONS

This study assessed the effectiveness of IC processes through telehealth compared to traditional in-person visits. Findings indicate that telehealth offers similar participant understanding and engagement while overcoming geographic and accessibility barriers. As health care adopts digital solutions, these results highlight telehealth's potential to improve recruitment and retention in clinical research, suggesting that policy makers should integrate telehealth practices into regulations for better access and health outcomes.

Building Community Resilience Through Trauma-Informed Solutions: Lessons Learned from a Social Accelerator in Rural North Carolina

Adverse childhood experiences and intergenerational trauma are associated with a variety of negative health outcomes and are particularly prevalent among people of color and those living in rural communities. The social accelerator model offers a novel means of assisting organizations in scaling up their initiatives and increasing their impact. This study investigates the lessons learned from adapting the social accelerator model to address community-level trauma and build resilience in a rural setting. We conducted qualitative interviews with program staff and the initial cohort of participants of the Resilient Leaders Initiative: a trauma-informed social accelerator designed for public institutions in Edgecombe County, North Carolina. Participating community organizations included a local high school, church, and courthouse. In-depth interviews (n = 23) explored strengths, challenges, and perceived outcomes of the program and were thematically analyzed. The program's deep community ties generated strong relationships among the cohort and created a safe space for participants to address trauma. Those interviewed identified the virtual program's flexible structure as a key strength, but also reported experiencing confusion around roles, outcomes, and program language. A shared passion for building community resilience among participants and staff served as a key motivator throughout the program. Findings indicate that a flexible environment, strong interpersonal relationships, and deep community roots are essential to facilitating the creation of trauma-informed solutions among community organizations via the social accelerator model.

Completion of registration of risk factor variables during telephone vs on-site follow-up after myocardial infarction: a nationwide observational study in 101 199 patients from contemporary clinical practice in Sweden

OBJECTIVES

The objective of this study was to assess the completeness of registration of secondary preventive variables comparing on-site visits with telephone consultations during follow-up after myocardial infarction.

DESIGN

This was an observational study based on the Swedish quality registry SWEDEHEART.

SETTING AND OUTCOME MEASURES

We analysed the proportion of missing values for major secondary preventive target data registered at the 2-month and 1-year follow-up visits, during 2006-2022 (n=101 199). χ2 tests were used to compare differences in data registration comparing on-site visits with telephone consultations. Patient characteristics and time trends in the proportion of missing values were also analysed.

RESULTS

Baseline characteristics for patients with on-site visits and telephone consultations were similar. At the 2-month follow-up, the proportion of missing data registered at on-site visits compared with telephone consultations was systolic blood pressure 2.4% (n=1729) vs 28.0% (n=5462), low-density lipoprotein cholesterol 9.1% (n=6525) vs 32.6% (n=6360), weight 20.1% (n=14 343) vs 43.0% (n=8401) and haemoglobin A1c for patients with diabetes mellitus 39.4% (n=4594) vs 69.4% (n=2225), p for all <0.0001. The differences were similar at the 1-year follow-up. Self-reported measures such as smoking status, level of physical activity and current medication had a low proportion of missing data (≤2.1%) for both follow-up modalities.

CONCLUSION

Registration of secondary preventive variables was less complete at telephone consultations compared with on-site cardiac rehabilitation follow-up visits, which might indicate lower quality of care during telephone follow-up. Further analysis on the possible impact of lack of registration of secondary preventive variables on patient outcomes is warranted.

Patterns of healthcare utilization according to health equity determinants during the first year of the pandemic at Johns Hopkins Medicine

Objectives

Rapid telehealth adoption happened at the onset of the coronavirus disease 2019 (COVID-19) pandemic, resulting in a move from in-person predominant to telehealth predominant care delivery. Later, in person visits rebounded with telehealth options remaining. This study aimed to assess differences in healthcare utilization during this changing landscape in terms of health equity determinants.

Materials and Methods

This was an observational cohort study of Johns Hopkins Medicine (JHM) patients. We analyzed utilization of video, telephone, and in-person patient-provider visits by eligible patients between March 16, 2019 and December 31, 2020. Percent changes in average weekly patient-provider visits from pre-pandemic (March 16, 2019-June 30, 2019) to early 2020 pandemic (March 16, 2020-June 30, 2020) and from pre-pandemic (July 1, 2019-December 31, 2019) to late 2020 pandemic (July 1, 2020-December 31, 2020). We used a quantile cut off technique to describe disproportionately smaller or greater drops in visits during the first year of the pandemic among health equity determinant groups and according to visit specialty, when compared to the total population.

Results

There was a 39% drop in patient-provider visits from the pre-pandemic to the early 2020 pandemic period, and a 24% drop from pre-pandemic to the late 2020 pandemic period. We discovered 21 groups according to health equity determinates and visit departments with patterns of disproportionately smaller or greater drops in visits during the first year of the pandemic, when compared to the total population: Pattern 1 -smaller drop in visits early and late 2020 (age 45-64, Medicare insurance, high poverty and high unemployment; mental health and medical specialty visits -P < .001); Pattern 2 -greater drop in visits early 2020 only (age 65-84; OB/GYN and surgical specialty visits-P < .001); Pattern 3 -greater drop in visits early and late 2020 (age 0-5, age 6-17, age 85+, Asian race, Hispanic or Latino ethnicity, private insurance-P < .001); and Pattern 4-smaller drop in visits in early 2020 when compared to late 2020. The age 18-44 group showed a smaller drop in visits early 2020 and then visit levels similar to the total population late 2020. Primary care visits were similar to the total population early 2020 and then a smaller drop in visits late 2020 (P < .001).

Discussion

Our study provides evidence of health equity determinant groups having disproportionally smaller or greater drops in visits during the first year of the pandemic. The observed differences may have been influenced by changing telehealth offerings during the first year of the pandemic. Groups with disproportionately smaller drops in visits early 2020 (Pattern #1 and age 18-44 group in Pattern #4), suggests more success with adopting telehealth among those groups. Whereas groups with disproportionately greater drops in visits early 2020 (Pattern #2 and Pattern #3), suggests less success with telehealth adoption. For Pattern #4, more clarification is needed on how changes in telehealth offerings contributed to the downward trend in visits observed from early to late 2020.

Conclusion

We describe 4 main patterns to characterize groups with disproportionately smaller or greater drops in visits during the first year of the pandemic. While this work did not specifically study vulnerable populations, these patterns set the stage for further studies of such groups.

Evaluation of a Virtual Health Hub for People Experiencing Homelessness in Sydney, Australia: Ensuring Physical and Psychological Primary Health Care in Crisis Accommodation

INTRODUCTION

Individuals experiencing homelessness have higher rates of chronic disease and face challenges accessing primary care. Virtual health care can reduce health inequity but needs user acceptance. A virtual health hub (VHH) for people experiencing homelessness in Sydney provided virtual GP and psychologist care within a crisis accommodation service. This included nursing assistance.

METHOD

The VHH evaluation assessed the feasibility of the service specifically examining accessibility, efficiency, costs, technology, quality, and outcomes through attendance data, patient measures, stakeholder interviews, and case studies.

FINDINGS

Data indicated 40% client utilisation with high attendance for GPs and/or psychologists. All clients reported a high quality of care, appointment benefits, understanding clinicians, and treatment help, and that privacy was maintained. If the VHH was not available, one-third would not have sought treatment. The majority agreed that virtual care was the same or better than in-person care. Only a few experienced technical issues. Service provider interviews indicated the benefits of accessible and affordable care, perceived reduced hospital presentations, staff time saved, and reduced client costs. Limitations were the lack of physical examinations and lack of follow-up due to temporary accommodation. Strong stakeholder partnerships enabled implementation success.

CONCLUSIONS

The VHH service is feasible and replicable with on-site assistance and stakeholder commitment.

Community-Level Internet Connectivity and Utilization of Maternal Telehealth

Background: The COVID-19 pandemic brought about a drastic increase in the utilization of telehealth services in place of or as a complement to in-person health services. Telehealth is a tool to help reduce disparities in the receipt of maternal health care. However, a stable internet connection is required for patients to connect to providers via telehealth; lack of internet connectivity is a barrier to maternal telehealth access. Methods: The objectives of this research were to determine whether community-level internet penetration is associated with community-level utilization of maternal telehealth services and assess the heterogeneity of this association across the maternal telehealth utilization spectrum. A cross-sectional study of community-level maternal telehealth is utilized in the United States in 2019. The underlying population is comprised of commercially insured maternal health patients receiving any antenatal, delivery-related, or postpartum care in the United States. The individual-level utilization data are aggregated to the geo-zip level (n = 404), which is a regional subdivision comprised of all zip codes that share the first three digits. Results: Findings show that the estimated relationship between the proportion of households with home-based internet connectivity was statistically significant at the 10th and 25th quantiles of maternal telehealth utilization. For these quantiles, an increase in community-level internet connectivity was associated with an increase in the utilization of maternal telehealth services. Conclusion: There is a positive association between community-level internet connectivity and maternal telehealth utilization, and the association varies in magnitude across the maternal telehealth utilization distribution. Policymakers should consider digital access when addressing telehealth policy for maternal care services.

Best Practices in Telecritical Care: Expert Consensus Recommendations From the Telecritical Care Collaborative Network

OBJECTIVES

Telecritical care (TCC) refers to the delivery of critical care using telehealth technologies. Despite increasing utilization, significant practice variation exists and literature regarding efficacy remains sparse. The Telecritical Care Collaborative Network sought to provide expert, consensus-based best practice recommendations for the design and delivery of TCC.

DESIGN

We used a modified Delphi methodology. Following literature review, an oversight panel identified core domains and developed declarative statements for review by an expert voting panel. During three voting rounds, voters agreed or disagreed with statements and provided open-ended feedback, which the oversight panel used to revise statements. Statements met criteria for consensus when accepted by greater than or equal to 85% of voters.

SETTING/SUBJECTS

The oversight panel included 18 multidisciplinary members of the TCC Collaborative Network, and the voting panel included 32 invited experts in TCC, emphasizing diversity of discipline, care delivery models, and geography.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified ten core domains: definitions/terminology; care delivery models; staffing and coverage models; technological considerations; ergonomics and workplace safety; licensing, credentialing, and certification; trust and relationship building; quality, safety, and efficiency, research agenda; and advocacy, leading to 79 practice statements. Of 79 original statements, 67 were accepted in round 1. After revision, nine were accepted in round 2 and two in round 3 (two statements were merged). In total, 78 practice statements achieved expert consensus.

CONCLUSIONS

These expert consensus recommendations cover a broad range of topics relevant to delivery of TCC. Experts agreed that TCC is most effective when delivered by care teams with specific expertise and by programs with explicit protocols focusing on effective communication, technical reliability, and real-time availability. Interventions should be tailored to local conditions. Although further research is needed to guide future best practice statements, these results provide valuable and actionable recommendations for the delivery of high-quality TCC.

Telemedicine as a tool for bridging geographical inequity: insights in geospatial interactions from a study on chronic heart failure patients

INTRODUCTION

Chronic heart failure patients experience large disparities in quality of and access to treatment, with rural populations receiving lower levels of care. Telemonitoring of patients is increasingly being used as an important tool for improving patient management and care and might reduce geographical inequities in healthcare.

METHODS

We investigate the presence and magnitude of a geospatial interaction effect on the health benefit of a supplementary telemedicine intervention, by analyzing the relationship between distance to regular place of treatment and the benefit of telemedicine in a secondary analysis of data from a previously conducted RCT. We use change in EQ5D health status, SF-36 Physical component score and SF-36 Mental component score as the outcomes. In the unadjusted analysis, intervention group and distance group and the interaction term are included as the independent variables, in the adjusted analysis, multiple socioeconomic and health related variables are included to account for potential confounders.

RESULTS

We find evidence of a significant interaction between the effects of telemedicine and long distance to treatment for change in EQ5D health status (unadjusted: p = 0.016, adjusted p = 0.009) and unadjusted but not adjusted mental component score (unadjusted: p = 0.013, adjusted p = 0.0728), for the change in physical component score the interaction term was not significant (unadjusted: p = 0.118, adjusted p = 0.092).

CONCLUSION

In our study we find that supplementary telemedicine is likely to reduce the health access inequities associated with geographical distance for chronic heart failure patients. However, our sample size was modest and further research is needed to confirm these findings.

Telemedicine is associated with reduced socioeconomic disparities in outpatient clinic no-show rates

INTRODUCTION

The global pandemic caused by coronavirus (COVID-19) sped up the adoption of telemedicine. We aimed to assess whether factors associated with no-show differed between in-person and telemedicine visits. The focus is on understanding how social economic factors affect patient no-show for the two modalities of visits.

METHODS

We utilized electronic health records data for outpatient internal medicine visits at a large urban academic medical center, from February 1, 2020 to December 31, 2020. A mixed-effect logistic regression was used. We performed stratified analysis for each modality of visit and a combined analysis with interaction terms between exposure variables and visit modality.

RESULTS

A total of 111,725 visits for 72,603 patients were identified. Patient demographics (age, gender, race, income, partner), lead days, and primary insurance were significantly different between the two visit modalities. Our multivariable regression analyses showed that the impact of sociodemographic factors, such as Medicaid insurance (OR 1.23, p < 0.01 for in-person; OR 1.03, p = 0.57 for telemedicine; p < 0.01 for interaction), Medicare insurance (OR 1.11, p = 0.04 for in-person; OR 0.95, p = 0.32 for telemedicine; p = 0.03 for interaction) and Black race (OR 1.36, p < 0.01 for in-person; OR 1.20, p < 0.01 for telemedicine; p = 0.03 for interaction), on increased odds of no-show was less for telemedicine visits than for in-person visits. In addition, inclement weather and younger age had less impact on no-show for telemedicine visits.

DISCUSSION

Our findings indicated that if adopted successfully, telemedicine had the potential to reduce no-show rate for vulnerable patient groups and reduce the disparity between patients from different socioeconomic backgrounds.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4003-4010, 2024.

Novel Characterization of Socioecological Determinants of Health in Rural Alabama

INTRODUCTION

Socioecological determinants of health (SEDOHs) influence disparities in surgical outcomes. However, SEDOHs are challenging to measure, limiting our ability to address disparities. Using a validated survey (SEDOH-88), we assessed SEDOHs in three rural communities in Alabama. We hypothesized that SEDOHs would vary significantly across sites but measuring them would be acceptable and feasible.

MATERIALS AND METHODS

This was a retrospective review of a prospectively maintained database involving surgical patients who completed the SEDOH-88 and a secondary survey assessing it's acceptability or feasibility from August 2021 to July 2023. Included patients underwent endoscopic, minimally invasive, or open surgery at three rural hospitals: Demopolis (DM), Alexander City (AC), and Greenville (GV).

RESULTS

The 107 participants comprised 48 (44.9%) from DM, 27 (25.2%) from AC, and 32 (29.9%) from GV, respectively. The median age was 64 y, and 65.6% were female. When comparing DM to AC and GV by individual factors, DM had the largest Black population (78.7 versus 22.2 versus 48.3%, P < 0.001) and more often required help reading hospital materials (20.5 versus 3.7 versus 10.3%, P = 0.007). When comparing DM to AC and GV by structural and environmental factors, DM had more Medicaid enrollees (27.3 versus 3.7 versus 6.9%, P = 0.033) and lacked fresh produce (18.2 versus 25.9 versus 39.3%, P = 0.033) and internet access (63.6 versus 100.0 versus 86.2%, P < 0.001). The SEDOH-88 had an overall 90.9% positive acceptability and feasibility score.

CONCLUSIONS

SEDOHs varied significantly across rural communities regarding individual (race or health literacy), structural (insurance), and environmental-level factors (nutritious food or internet access). The high acceptability and feasibility of the SEDOH-88 shows it's potential utility in identifying targets for future disparity-reducing interventions.

Geospatial Demand for Approved Cleft Care in the United States

Background

Geographic information systems are powerful tools for characterizing the geospatial factors influencing access to care. As patients with cleft lip and/or palate (CL/P) require long-term care, with numerous operations and therapies, access to timely, quality care is extremely important. This study uses population level analysis and geographic information systems to identify United States counties with limited access to American Cleft Palate Association-approved cleft teams.

Methods

Natality data were queried from the National Vital Statistics System. Population and geographic data were obtained from the US Census Bureau. The Social Vulnerability Index (SVI) was utilized to account for social inequality. Total births with CL/P, population estimates, SVI, distance to the nearest center, and total centers within 50 km were used to generate the cleft care demand index (CCDI).

Results

Ninety-two counties had CCDIs between 66.7 and 100. The highest scoring county, Hidalgo County, Texas, had 62 births with CL/P, population estimate of 888,367 persons, distance to the nearest cleft center of 368.4 km, and SVI of 0.99.

Conclusions

This study demonstrates the power of geographic information systems for identifying areas with limited access to approved cleft teams. The CCDI measures cleft burden, socioeconomic disadvantage, and geographic barriers to quantify the demand for approved cleft care in each county. Utilizing these scores can help direct future interventions, outreach efforts, and cleft care center planning.

"A day in the life" - telemedicine in family medicine and its relationship with practicing physicians' satisfaction: a cross-sectional study

BACKGROUND

Telemedicine has expanded rapidly in recent years, and many encounters that were conducted in person now take place remotely. This study aimed to assess primary care physicians' (PCPs) attitudes towards the different modalities of patient care.

METHODS

This is a cross-sectional nationwide descriptive study conducted in Israel. We asked PCPs to document an entire workday and answer a short questionnaire after each visit. The questions addressed the type of visit (face-to-face, remote synchronous [telephone/video], or remote asynchronous [online requests]), the perceived quality of the visit, and the physicians' feelings at the end of each visit. Before documenting their working day, we asked the participants to answer a questionnaire about their general attitudes toward different modalities of medical visits and how they affect their well-being and burnout.

RESULTS

Sixty physicians documented 2,025 visits, of which 39% took place in person, 36% stemmed from online patient requests, 18% were telephone meetings, < 1% were video meetings, and 6% consisted of other types of contact. Mixed effects logistic regressions were used to model the visits' evaluation. The odds ratios (ORs) for perceived medical quality of visits focused on medical tasks were lower for non-face-to-face visits: OR = 0.39, 95% CI 0.25-0.59 for remote synchronous, and OR = 0.14, 95% CI 0.09-0.23 for remote asynchronous. The perceived medical quality of visits focused on administrative tasks was lower for remote asynchronous than for face-to-face visits (OR = 0.31, 95% CI 0.14-0.65). We found no association between medical quality and patients, physicians, or clinic characteristics. The inappropriateness of the visit modality was also associated with lower medical quality (OR = 0.13, 95% CI 0.09-0.18). We found a correlation between perception of medical quality and physicians' feelings at the end of the visits, Spearman's r = 0.82 (p < 0.001).

CONCLUSIONS

A substantial portion of the visits was dedicated to administrative tasks and remote medicine. In comparison, physicians rated face-to-face visits' quality higher than remote visits. Policymakers should intervene to minimize administrative work, reduce PCPs' administrative workload, and direct patients to the optimal visit modality for their complaints. These steps would increase medical quality, reduce burnout, and mitigate the shortage of PCPs.

Disparities in Maternal Health Visits Between Rural and Urban Communities in the United States, 2016-2018

OBJECTIVE

The objective was to estimate the rural-urban differences in the receipt of prepregnancy, prenatal, and postpartum services.

METHODS

The authors conducted a cross-sectional data analysis using data from the Pregnancy Risk Assessment and Monitoring System from 2016 to 2018 to analyze rural-urban differences in the receipt of medical visits and care content delivery during the prepregnancy year, as well as the prenatal and postpartum periods among birthing people in the US, using survey-weighted multivariable logistic regression models.

RESULTS

Rural-dwelling birthing people were significantly less likely to attend a medical visit in the prepregnancy year or postpartum period, even when controlled for sociodemographic and clinical characteristics. Compared to their urban counterparts, they were also less likely to receive comprehensive screening and counseling in the prepregnancy and postpartum maternity phases.

CONCLUSION

Efforts to ameliorate rural-urban differences in maternal care access and quality should explicitly adopt multilevel, systemic approaches to policy and program implementation and evaluation. Policymakers and practitioners should consider telehealth as a potential complementary tool to minimize gaps in quality of care which disproportionately impact rural-dwelling birthing people.

Designing remote synchronous auditory comprehension assessment for severely impaired individuals with aphasia

BACKGROUND

The use of telepractice in aphasia research and therapy is increasing in frequency. Teleassessment in aphasia has been demonstrated to be reliable. However, neuropsychological and clinical language comprehension assessments are not always readily translatable to an online environment and people with severe language comprehension or cognitive impairments have sometimes been considered to be unsuitable for teleassessment.

AIM

This project aimed to produce a battery of language comprehension teleassessments at the single word, sentence and discourse level suitable for individuals with moderate-severe language comprehension impairments.

METHODS

Assessment development prioritised response consistency and clinical flexibility during testing. Teleassessments were delivered in PowerPoint over Zoom using screen sharing and remote control functions. The assessments were evaluated in 14 people with aphasia and 9 neurotypical control participants. Modifiable assessment templates are available here: https://osf.io/r6wfm/.

MAIN CONTRIBUTIONS

People with aphasia were able to engage in language comprehension teleassessment with limited carer support. Only one assessment could not be completed for technical reasons. Statistical analysis revealed above chance performance in 141/151 completed assessments.

CONCLUSIONS

People with aphasia, including people with moderate-severe comprehension impairments, are able to engage with teleassessment. Successful teleassessment can be supported by retaining clinical flexibility and maintaining consistent task demands.

WHAT THIS PAPER ADDS

What is already known on the subject Teleassessment for aphasia is reliable but assessment of auditory comprehension is difficult to adapt to the online environment. There has been limited evaluation of the ability of people with severe aphasia to engage in auditory comprehension teleassessment. What this paper adds to existing knowledge Auditory comprehension assessment can be adapted for videoconferencing administration while maintaining clinical flexibility to support people with severe aphasia. What are the potential or actual clinical implications of this work? Teleassessment is time and cost effective and can be designed to support inclusion of severely impaired individuals.

Impact of Remote Medical Devices on Utilization of Medical Services in Pediatric Patients with Upper Respiratory Infections: A Retrospective Study

Background: Remote mobile examination devices in telemedicine are a new technology in healthcare. Objective: To assess the utilization of visits using remote medical devices. Methods: A retrospective analysis of follow-up visits, referrals, laboratory testing and antibiotic prescriptions of 470,845 children's video visits with and without remote medical examination device and in-clinic visits. Results: Rates of follow-up visits, referrals and laboratory tests were higher in video visits compared to visit with medical device (OR of 1.27, 1.08, 1.93 respectfully). For in-clinic visits, rates of follow-up were lower but higher for referrals to subspecialists and laboratory test referrals when compared to telemedicine. Antibiotic prescriptions were provided at a lower rate in video visits compared to visits with a medical device (OR = 0.48) and in-clinic visits. Conclusions: Incorporating a remote medical device may reduce follow up visits, referrals and laboratory tests compared to a video visit without a device. The prevalence of antibiotic prescriptions did not escalate in telemedicine consultations.

Telemedicine with special focus on allergic diseases and asthma-Status 2022: An EAACI position paper

Efficacious, effective and efficient communication between healthcare professionals (HCP) and patients is essential to achieve a successful therapeutic alliance. Telemedicine (TM) has been used for decades but during the COVID-19 pandemic its use has become widespread. This position paper aims to describe the terminology and most important forms of TM among HCP and patients and review the existing studies on the uses of TM for asthma and allergy. Besides, the advantages and risks of TM are discussed, concluding that TM application reduces costs and time for both, HCP and patients, but cannot completely replace face-to-face visits for physical examinations and certain tests that are critical in asthma and allergy. From an ethical point of view, it is important to identify those involved in the TM process, ensure confidentiality and use communication channels that fully guarantee the security of the information. Unmet needs and directions for the future regarding implementation, data protection, privacy regulations, methodology and efficacy are described.

Determinants of non-attendance at face-to-face and telemedicine ophthalmic consultations

BACKGROUND/AIMS

Evaluation of telemedicine care models has highlighted its potential for exacerbating healthcare inequalities. This study seeks to identify and characterise factors associated with non-attendance across face-to-face and telemedicine outpatient appointments.

METHODS

A retrospective cohort study at a tertiary-level ophthalmic institution in the UK, between 1 January 2019 and 31 October 2021. Logistic regression modelled non-attendance against sociodemographic, clinical and operational exposure variables for all new patient registrations across five delivery modes: asynchronous, synchronous telephone, synchronous audiovisual and face to face prior to the pandemic and face to face during the pandemic.

RESULTS

A total of 85 924 patients (median age 55 years, 54.4% female) were newly registered. Non-attendance differed significantly by delivery mode: (9.0% face to face prepandemic, 10.5% face to face during the pandemic, 11.7% asynchronous and 7.8%, synchronous during pandemic). Male sex, greater levels of deprivation, a previously cancelled appointment and not self-reporting ethnicity were strongly associated with non-attendance across all delivery modes. Individuals identifying as black ethnicity had worse attendance in synchronous audiovisual clinics (adjusted OR 4.24, 95% CI 1.59 to 11.28) but not asynchronous. Those not self-reporting their ethnicity were from more deprived backgrounds, had worse broadband access and had significantly higher non-attendance across all modes (all p<0.001).

CONCLUSION

Persistent non-attendance among underserved populations attending telemedicine appointments highlights the challenge digital transformation faces for reducing healthcare inequalities. Implementation of new programmes should be accompanied by investigation into the differential health outcomes of vulnerable populations.

Does digital infrastructure improve public Health? A quasi-natural experiment based on China's Broadband policy

This study proposed a scheme for improving people's health from the perspective of digital infrastructure construction. We used the China Family Panel Studies conducted between 2010 and 2020 and the digital infrastructure construction marked by the Broadband China policy between 2014 and 2016 as a quasi-natural experiment. We adopted the multi-time difference-in-differences method to identify the causal relationship between digital infrastructure and people's health. We found that digital infrastructure construction significantly improved people's health, and the effect was more prominent among young and middle-aged residents and those with less than a university education. Moreover, digital infrastructure construction improved the utilization of medical services, helped residents develop healthy lifestyles, and increased people's health investments. Additionally, digital infrastructure reduced health inequality among people and promoted health equity. The findings could guide future policies to improve people's health and well-being.

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.

Quantifying Urban-Rural Inequality in Access to Telemedicine: Descriptive Analysis of Telemedicine Uses and Providers in Japan Under COVID-19

Background: COVID-19 has reportedly resulted in disparities in the use of telemedicine due to several socioeconomic factors. While telemedicine was developed to overcome geographical distance, under COVID-19 telemedicine conversely might have deepened the urban-rural telemedicine divide. Especially in Japan, the authority has virtually regulated distant telemedicine use, which favored telemedicine providers who are located in close proximity to patients. This study aimed to quantify the urban-rural disparity in access to telemedicine and investigate heterogeneity between devices (phone and video visits). Methods: We used two nationally comprehensive data sources in Japan. One was a municipality-level telemedicine provider database. Municipality-provider-level analysis intended to measure the uneven distribution of telemedicine providers compared to usual health care providers as well as the difference among clinical departments. The second source was prefecture-level telemedicine utilization data. Prefecture-utilization-level analysis aimed to quantify how the use of telemedicine converged in urban areas. We investigated the heterogeneity between types of devices and time periods. To measure inequality, this study used the Lorenz Curve and Gini coefficients. Ethical review was not required. Results: The data included 16,927 providers (14,111 clinics and 2,816 hospitals) and 88,952 first visits throughout Japan. The main findings were the geographically converged distribution of telemedicine providers compared with overall providers who were not limited to telemedicine and, possibly as a result of it, the geographically unequal utilization of telemedicine compared with in-person visits. Furthermore, video visits were more unequally utilized than phone visits, let alone in-person visits. The disparity was not resolved over time, which implied a systematic cause. Conclusion: Using comprehensive nationwide data, this study revealed geographical inequality relating to access to telemedicine under the COVID-19 special deregulation in Japan. While telemedicine initially aimed to provide access to care for people in rural areas, several factors, including the digital divide, COVID-19, and the Japanese policy, paradoxically could have caused this disparity.

Patient Characteristics Associated With Phone and Video Visits at a Tele-Urgent Care Center During the Initial COVID-19 Response: Cross-Sectional Study

BACKGROUND

Health systems rapidly adopted telemedicine as an alternative health care delivery modality in response to the COVID-19 pandemic. Demographic factors, such as age and gender, may play a role in patients' choice of a phone or video visit. However, it is unknown whether there are differences in utilization between phone and video visits.

OBJECTIVE

This study aimed to investigate patients' characteristics, patient utilization, and service characteristics of a tele-urgent care clinic during the initial response to the pandemic.

METHODS

We conducted a cross-sectional study of urgent care patients using a statewide, on-demand telemedicine clinic with board-certified physicians during the initial phases of the pandemic. The study data were collected from March 3, 2020, through May 3, 2020.

RESULTS

Of 1803 telemedicine visits, 1278 (70.9%) patients were women, 730 (40.5%) were aged 18 to 34 years, and 1423 (78.9%) were uninsured. There were significant differences between telemedicine modalities and gender (P<.001), age (P<.001), insurance status (P<.001), prescriptions given (P<.001), and wait times (P<.001). Phone visits provided significantly more access to rural areas than video visits (P<.001).

CONCLUSIONS

Our findings suggest that offering patients a combination of phone and video options provided additional flexibility for various patient subgroups, particularly patients living in rural regions with limited internet bandwidth. Differences in utilization were significant based on patient gender, age, and insurance status. We also found differences in prescription administration between phone and video visits that require additional investigation.

Preferences for virtual versus in-person mental and physical healthcare in Canada: a descriptive study from a cohort of youth and their parents enriched for severe mental illness

BACKGROUND

Virtual care may improve access to healthcare and may be well suited to digitally connected youth, but experts caution that privacy and technology barriers could perpetuate access inequities. Success of virtual care will depend on its alignment with patient preferences. However, information on preferences for virtual and in-person healthcare is missing, especially for youth. We sought to quantify preferences for and barriers to virtual versus in-person mental and physical healthcare in youth and their parents, including in vulnerable segments of the population such as families with a parent with severe mental illness (SMI).

METHODS

Participants were 219 youth and 326 parents from the Families Overcoming Risks and Building Opportunities for Wellbeing cohort from Canada, of which 61% of youth had at least one parent with SMI. Participants were interviewed about healthcare preferences and access to privacy/technology between October 2021 and December 2022.

RESULTS

Overall, youth reported a preference for in-person mental (66.6%) and physical healthcare (74.7%) versus virtual care or no preference, and to a somewhat lesser degree, so did their parents (48.0% and 53.9%). Half of participants reported privacy/technology barriers to virtual care, with privacy being the most common barrier. Preferences and barriers varied as a function of parent SMI status, socioeconomic status and rural residence.

CONCLUSIONS

The majority of youth and parents in this study prefer in-person healthcare, and the preference is stronger in youth and in vulnerable segments of the population. Lack of privacy may be a greater barrier to virtual care than access to technology.

The evolution of health system planning and implementation of maternal telehealth services during the COVID-19 Pandemic

Background

Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap.

Objective

This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered.

Methods

We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach.

Results

Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients.

Conclusion

Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist.

Cardiovascular disease risk management during COVID-19: in-person vs virtual visits

OBJECTIVES

Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits.

STUDY DESIGN

Retrospective interrupted time-series analysis.

METHODS

Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding.

RESULTS

There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality.

CONCLUSIONS

Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Telehealth Use by Pregnancy Stage Among Commercially Insured Patients in the United States, 2016-2019

Introduction: Relatively little is known about the proportion of maternal health services utilized through telehealth and whether rural-urban disparities in telehealth use exist throughout antenatal, delivery, and postpartum phases of maternal services. In this study, we describe patterns of care, including telehealth utilization, by rurality and racial/ethnic composition of the health service area during the antenatal, labor/delivery, and postpartum stages of pregnancy among commercially insured patients between 2016 and 2019. Methods: We present univariate and comparative descriptive statistics of patient and facility characteristics and site of care by the degree of rurality and racial/ethnic composition of the health service area (defined as geozips). The individual-level utilization data for 238,695 patients were aggregated to the geo-zip level (n = 404). Results: Between 2016 and 2019, 3.5% of pregnancy, delivery, and postpartum-related visits among commercially insured patients were delivered through telehealth. Telehealth use was higher in the antenatal (3.5% of claim lines) and postpartum (4.1% of claim lines) periods, compared with labor and delivery (0.7% of claim lines). We also found that the proportion of telehealth services (of total services billed) increased with the share of Black and Latinx residents at the geozip level. Discussion: Our findings highlight disparities in telehealth use, consistent with findings from studies using different data sources and time periods. Future research is needed to examine whether the relative differences in proportion of telehealth services, even if small, are associated with telehealth capacity in the hospital or community and why the proportion of telehealth services differs across community-level characteristics, specifically rurality and proportion of Black and Latinx residents.

How is digital health suitability measured for communities? A systematic review

Background

Digital health services continue growing in usage and popularity, with patients and healthcare organizations benefiting from their use. Despite this, no mechanism exists to measure a patient's and community's suitability to leverage these services.

Objective

This systematic review aims to evaluate the extent and nature of measuring the overall suitability of individuals and communities within the digital health landscape.

Methods

Database searches in February 2024 across PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, and IEEE Xplore yielded 1044 unique references. Two screening stages resulted in 10 articles that met all evaluation criteria for review inclusion.

Results

This systematic review found a gap in the ability to holistically assess a patient's and community's suitability to access digital health services. Myriad indices and tools identify isolated factors contributing to digital health accessibility (e.g., broadband availability); however, no comprehensive mechanism adequately informs providers, policymakers, and researchers.

Conclusion

A comprehensive index that accurately reflects suitability for digital health services is needed. Index factors should include a combination of indicators related to socioeconomic status, digital accessibility, such as device and internet access, and social determinants of health. Together, these form the predominant driving factors related to one's ability to participate in digital health services.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

A comparison between perceived rurality and established geographic rural status among Indiana residents

The study assessed the association and concordance of the traditional geography-based Rural-Urban Commuting Area (RUCA) codes to individuals' self-reported rural status per a survey scale. The study included residents from rural and urban Indiana, seen at least once in a statewide health system in the past 12 months. Surveyed self-reported rural status of individuals obtained was measured using 6 items with a 7-point Likert scale. Cronbach's alpha was used to measure the internal consistency between the 6 survey response items, along with exploratory factor analysis to evaluate their construct validity. Perceived rurality was compared with RUCA categorization, which was mapped to residential zip codes. Association and concordance between the 2 measures were calculated using Spearman's rank correlation coefficient and Gwet's Agreement Coefficient (Gwet's AC), respectively. Primary self-reported data were obtained through a cross-sectional, statewide, mail-based survey, administered from January 2018 through February 2018, among a random sample of 7979 individuals aged 18 to 75, stratified by rural status and race. All 970 patients who completed the survey answered questions regarding their perceived rurality. Cronbach's alpha value of 0.907 was obtained indicating high internal consistency among the 6 self-perceived rurality items. Association of RUCA categorization and self-reported geographic status was moderate, ranging from 0.28 to 0.41. Gwet's AC ranged from -0.11 to 0.26, indicating poor to fair agreement between the 2 measures based on the benchmark scale of reliability. Geography-based and self-report methods are complementary in assessing rurality. Individuals living in areas of relatively high population density may still self-identify as rural, or individuals with long commutes may self-identify as urban.

Foundational domains and competencies for baccalaureate health informatics education

BACKGROUND

Foundational domains are the building blocks of educational programs. The lack of foundational domains in undergraduate health informatics (HI) education can adversely affect the development of rigorous curricula and may impede the attainment of CAHIIM accreditation of academic programs.

OBJECTIVE

This White Paper presents foundational domains developed by AMIA's Academic Forum Baccalaureate Education Committee (BEC) which include corresponding competencies (knowledge, skills, and attitudes) that are intended for curriculum development and CAHIIM accreditation quality assessment for undergraduate education in applied health informatics.

METHODS

The AMIA BEC used the previously published master's foundational domains as a guide to creating a set of competencies for health informatics at the undergraduate level to assess graduates from undergraduate health informatics programs for competence at graduation. A consensus method was used to adapt the domains for undergraduate level course work and harmonize the foundational domains with the currently adapted domains for HI master's education.

RESULTS

Ten foundational domains were developed to support the development and evaluation of baccalaureate health informatics education.

DISCUSSION

This article will inform future work towards building CAHIIM accreditation standards to ensure that higher education institutions meet acceptable levels of quality for undergraduate health informatics education.

Cost analysis and economic evaluation of a virtual pediatric emergency department pilot program

OBJECTIVES

The Children's Hospital of Eastern Ontario launched Canada's first virtual pediatric emergency department (ED) from May 2020 through November 2021 to deliver accessible care during the COVID-19 pandemic. The objective of this study was to (i) conduct a cost analysis of the virtual pediatric ED, and (ii) compare the virtual costs to in-person ED costs to inform future resource allocation decisions.

METHODS

We calculated costs from a health system perspective in 2021 Canadian dollars. Using a decision tree model, we compared expected costs with and without the virtual pediatric ED, and calculated overall and per patient cost savings of implementing the virtual ED.

RESULTS

The virtual ED provided care to 7394 patients. In the base case, virtual care saved $890,000 ($120 per patient). One-way sensitivity analyses suggest overall cost savings were most sensitive to the proportion of virtual care patients who would have received in-person care had the virtual option not been available (range $300,000-$1,700,000), followed by ED overhead costs (range $640,000-$1,140,000). Multivariate sensitivity analyses demonstrated robust cost savings of $920,000 (95% CI 850,000-990,000) in a scenario using billing codes to calculate costs, and savings of $1,040,000 (95% CI 960,000-1,120,000) if physician salaries were used instead.

CONCLUSIONS

These findings suggest the virtual pediatric ED reduced costs per patient. Virtual care may represent a financially valuable pediatric emergency department service.

Health equity: A concept analysis

BACKGROUND

Although health equity is critically important for healthcare delivery, there are inconsistencies in its definitions or lack of definitions.

PURPOSE

Develop a comprehensive understanding of health equity to guide nursing practice and healthcare policy.

METHOD

Walker and Avant's concept analysis method was used to establish defining attributes, antecedents, consequences, and empirical referents of health equity.

FINDINGS

Health equity defining attributes are grounded in ethical principles, the absence of unfair and avoidable differences, and fair and just opportunities to attain a person's full health potential. Health equity antecedents are categorized into environmental; financial or economic; law, politics, and policy; societal and structural; research; and digital and technology.

DISCUSSION

Health equity's antecedents are useful to distinguish health disparities from health outcomes resulting from individual preferences. To achieve health equity, organizations need to focus on addressing the antecedents.

Lessons Learned from the COVID-19 Pandemic: A Survey-Based Study on a Sample of Italian Physicians' Opinions on Telemedicine

Telemedicine was born out of the need to ensure clinical evaluation and personal care regardless of the physical presence of the healthcare professional nearby. Information technologies have been vital during the COVID-19 pandemic to ensure medical care and avoid the contagion between patients and clinicians. Accordingly, telecare services multiplied worldwide and gained paramount importance. The present work aims to collect field-based opinions about Telemedicine and ethics among Italian physicians. We developed a web-based questionnaire that was administered to Italian physicians from 1 May to 15 June 2022. The questionnaire was distributed as a link to Google Forms via social networks/instant messaging applications to groups of graduated and qualified physicians. A total of 180 physicians answered the questionnaire (with an age range from 25 to 68 years old). Physicians belonging to the medical area of expertise appear to more frequently use new technologies in comparison to other specialties. The vast majority believe that it is appropriate to use Telemedicine for monitoring and follow-up but not for evaluating a new patient. Concerns about changes in the physician-patient relationship, informed consent, digital barrier, and privacy and data protection also emerged. Finally, telehealth is thought to be a potential useful tool for the future by the majority of respondents but proper training for physicians is therefore needed.

Greater Telehealth Use Results in Increased Visit Frequency and Lower Physician Related-Distress in Adolescents and Young Adults With Type 1 Diabetes

BACKGROUND

Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed.

METHODS

A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study.

RESULTS

Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .03).

CONCLUSIONS

Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.

Tracking the digital health gap in elderly: A study in Italian remote areas

The Covid-19 pandemic has provided a major innovative thrust to public services regarding their digitization to continue providing an effective response to the population's needs and to reduce management costs. However, there has been a partial lack of those welfare policies that can provide an adequate response to the elderly segment of the population, which is most affected by the introduction of new technologies into the public sphere. This study analyses the digital gap in health in the elderly living in remote areas of Italy and investigates the use of digital devices for health purposes. It compares the use of digital solutions for health with people's common digital competencies and their willingness to use them. A descriptive analysis of the sample was constructed to verify the different responses of the elderly by age, gender, educational qualification, and geographic area. Furthermore, regression analyses have been conducted to test whether there is any dependent effect among the elderly's characteristics or geographic areas. The results highlight the existence of a potential digital health gap among the elderly in remote areas of Italy both due to infrastructural issues and the lack of digital skills. The latter are positively correlated with educational qualification, such that it is also possible to highlight differences between age groups analysed and shape future welfare policies to reduce digital inequality.

Remote Provision of Medication Abortion and Contraception Through Telemedicine

This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.

Scoping Review of Pulmonary Telemedicine Consults: Current Knowledge and Research Gaps

Rationale: Telemedicine consults, including video consults, telephone consults, electronic consults, and virtual conferences, may be particularly valuable in the management of chronic pulmonary diseases, but there is limited guidance on best practices for pulmonary telemedicine consults. Objectives: This scoping review aims to identify, characterize, and analyze gaps in the published literature on telemedicine consults health providers use to manage patients with chronic pulmonary diseases. Methods: We searched PubMed, Embase, Web of Science, and Cochrane Library from database origin through July 10, 2021. We included manuscripts describing applications of telemedicine consults for patients with chronic pulmonary diseases (asthma, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and interstitial lung disease). We restricted our review to full-length articles published in English about provider-led (as opposed to nurse-led) telemedicine consults. Results: Our search yielded 3,118 unique articles; 27 articles met the inclusion criteria. All telemedicine consult modalities and chronic pulmonary conditions were well represented in the review except for pulmonary hypertension and interstitial lung disease, which were represented by one and no articles, respectively. Most articles described a small, single-center, observational study that focused on the acceptability, feasibility, use, and/or clinical effectiveness of the telemedicine consult. Few studies had objectively measured clinical outcomes or included a comparator group, and none compared telemedicine consult modalities against one another. Conclusions: Our scoping review identified limited literature describing pulmonary telemedicine consults and highlighted several gaps in the literature that warrant increased attention. Providers treating chronic pulmonary diseases are left with limited guidance on best practices for telemedicine consults.

Examining Contextual Influences Affecting health-related Quality of life Among under-resourced Appalachian Patients Attending pop-up Medical Clinics

Appalachian residents face substantial barriers to accessing health care and these barriers have negative ramifications for this community's health-related quality of life (HRQoL) [1, 2]. Pop-up medical clinics address some of these barriers by offering a range of free health care services throughout Appalachia. Although these services are undoubtedly helpful, information on how these clinics may be linked to HRQoL changes among under-resourced communities is limited. The present study is among the first to examine how (1) individuals attending pop-up medical clinics present on HRQoL indicators, (2) how HRQoL changes 3-months post-clinic, and (3) how individual, social, and community factors interact with HRQoL at presentation and change in HRQoL 3-months post-clinic. Data were collected from 243 individuals attending one of seven pop-up medical clinics across Central, South Central, and Southern Appalachia. During the week of the clinic, participants completed a survey assessing individual, social, and community factors as well as HRQoL variables (i.e., overall health, depressive symptoms, pain, sleep quality, and several physical symptoms). Participants completed the same survey 3-months post-clinic. Results revealed that baseline individual, social, and community factors were predictive of HRQoL indicators at baseline; individual and social factors also uniquely predicted change in HRQoL at 3-months post-clinic. Within the Social Ecological Framework, these data emphasize the significance of individual and social level factors on an individual's HRQoL. Clinical implications and directions for future research are discussed.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care

Importance

Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery.

Objective

To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care.

Design, Setting, and Participants

This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery.

Exposures

Telemedicine-based preoperative care.

Main Outcomes and Measures

Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure.

Results

A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02).

Conclusions and Relevance

In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Experience and Attitudes Toward Telehealth in Student-Run Free Clinics (SRFC)

INTRODUCTION/OBJECTIVES

Telehealth services expanded during the coronavirus disease 2019 (COVID-19) pandemic. Student-run free clinics (SRFC) deliver important health care services to underserved populations, who may face barriers to telehealth use. This study characterizes telehealth usage, experiences, and attitudes among individuals working in SRFCs.

METHODS

In November 2021, a survey adapted from the COVID-19 Healthcare Coalition Telehealth Impact Physician Survey was sent to all registrants who identified themselves as students at the 2020 Society of Student-Run Free Clinics Annual Conference.

RESULTS

Thirty-eight individuals of 576 registrants (7%) representing 21 of 88 (24%) SRFCs completed the survey. Twenty-one (58%) individuals reported using telehealth in their clinic. Those that did not cited lack of infrastructure as a barrier (eg, broadband, Internet challenges, technology investments), were more likely to serve homeless (P = .01), and less likely to serve non-English speaking populations (P = .02). There were increases in telehealth and decreases in in-person visits after March 11, 2020 though changes did not reach statistical significance. At least 15 (68%) wanted to continue chronic disease management, preventative care, and mental/behavioral health via telehealth after COVID-19. Most felt that telehealth was easy to use and improved the health, safety, and timeliness of care of patients, but not work satisfaction or access to care. Difficulty accessing physical devices, Internet, and data was the most-cited barrier to maintaining and accessing telehealth.

CONCLUSIONS

Nearly all participants cited significant benefits and barriers to telehealth that impacted perceived access to care and sustainability. SRFCs' experiences may be modulated by their underserved populations and role in student education. Addressing barriers, particularly patient- and clinic-level technology challenges, could work to improve inequities in telehealth uptake.

Integration of Case-Based Dialogue to Enhance Medical Students' Understanding of Using Health Communication to Address Social Determinants of Health

BACKGROUND AND OBJECTIVES

With the ever-growing diversity within our communities, it is imperative that we integrate social determinants of health (SDOH) such as racial disparity, economic instability, lack of transportation, intimate partner violence, and limited social supports, and the importance of health literacy into undergraduate medical education. By incorporating evidence-based curriculum on the disproportionality within healthcare faced by racial and ethnic minorities, we have the opportunity to develop more culturally sensitive providers. The purpose of this study was to assess the impact of a case-based debrief experience on medical students' knowledge about how social determinants of health can impact health and healthcare within a family medicine clinical setting and their intent to practice in an underserved community.

METHODS

We utilized a retrospective paired-sample t-test analysis of program data from 640 third-year medical students who engaged in a family medicine clerkship between July 2020, and April 2022. For inclusion in the study, students must have engaged in a case-based exercise and corresponding small group debrief around the impact of social determinants of health on patient care.

RESULTS

We found a statistically significant improvement in students' reported knowledge about SDOH, as well as the confidence and intent to work with and care for individuals of diverse cultural and socioeconomic backgrounds.

CONCLUSION

Medical students must have the knowledge and self-efficacy to understand how social determinants of health can impact health and healthcare within a family medicine clinical setting. As a result of integrating more active learning strategies such as the case-base and debrief experience, students may have a more robust medical education experience.

Aging in Rural Communities

Purpose of Review

Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities.

Recent Findings

The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted.

Summary

Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

Patients’ preferences for telemedicine versus in-clinic consultation in primary care during the COVID-19 pandemic

Background

The Hybrid Patient Care system integrates telehealth and in-clinic consultation. While COVID-19 increased telehealth use, healthcare providers are still seeking the best combination of virtual and in-clinic consultation. Understanding patients’ tele-consultation-related preferences is vital for achieving optimal implementation. The discrete choice experiment (DCE) is the stated preference technique for eliciting individual preferences and is increasingly being used in health-related applications.

The study purpose was to evaluate attributes and levels of the DCE regarding patients’ preferences for telemedicine versus traditional, in-clinic consultation in primary care during the COVID-19 pandemic, in order to facilitate successful implementation.

Methods

A three-phase structure was used in the qualitative stage of the DCE: (1) a literature review and preparation of interview guides; (2) Eight focus group interviews comprised of 26 patients and 33 physicians; and (3) Attribute selection: a ranking exercise among 48 patients. The Think Aloud technique, in which respondents are asked to verbalize their thoughts, was used in the focus groups. Interview data were analyzed by thematic analysis.

Results

Eight attributes were proposed by the patients in the focus groups. The four most important attributes were then selected in pre-testing, and are described in this study: Availability, time until the appointment, severity of the medical problem, patient-physician relationship, and flexible reception hours.

Conclusions

This study has a theoretical contribution in post-COVID-19 patients’ preferences in Hybrid Medicine patient care. This provides a foundation to assess the rigors of this stage and provide additional evidence to the limited existing literature on attributes development for DCE patient preferences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01640-y.

Measuring rurality in health services research: a scoping review

PURPOSE

This study is a scoping review of the different methods used to measure rurality in the health services research (HSR) literature.

METHODS

We identified peer-reviewed empirical studies from 2010-2020 from seven leading HSR journals, including the Journal of Rural Health, that used any definition to measure rurality as a part of their analysis. From each study, we identified the geographic unit (e.g., county, zip code) and definition (e.g., Rural Urban Continuum Codes, Rural Urban Commuting Areas) used to classify categories of rurality. We analyzed whether geographic units and definitions used to classify rurality differed by focus area of studies, including costs, quality, and access to care. Lastly, we examined the number of rural categories used by authors to assess rural areas.

FINDINGS

In 103 included studies, five different geographic units and 11 definitions were used to measure rurality. The most common geographic units used to measure rurality were county (n = 59, 57%), which was used most frequently in studies examining cost (n = 12, 75%) and access (n = 33, 57.9%). Rural Urban Commuting Area codes were the most common definition used to measure rurality for studies examining access (n = 13, 22.8%) and quality (n = 10, 44%). The majority of included studies made rural versus urban comparisons (n = 82, 80%) as opposed to focusing on rural populations only (n = 21, 20%). Among studies that compared rural and urban populations, most studies used only one category to identify rural locations (n = 49 of 82 studies, 60%).

CONCLUSION

Geographic units and definitions to determine rurality were used inconsistently within and across studies with an HSR focus. This finding may affect how health disparities by rural location are determined and thus how resources and federal funds are allocated. Future research should focus on developing a standardized system to determine under what circumstances researchers should use different geographic units and methods to determine rurality by HSR focus area.

'Much more convenient, just as effective': Experiences of starting continuous glucose monitoring remotely following Type 1 diabetes diagnosis

AIM

Initiating continuous glucose monitoring (CGM) shortly after Type 1 diabetes diagnosis has glycaemic and quality of life benefits for youth with Type 1 diabetes and their families. The SARS-CoV-2 pandemic led to a rapid shift to virtual delivery of CGM initiation visits. We aimed to understand parents' experiences receiving virtual care to initiate CGM within 30 days of diagnosis.

METHODS

We held focus groups and interviews using a semi-structured interview guide with parents of youth who initiated CGM over telehealth within 30 days of diagnosis during the SARS-CoV-2 pandemic. Questions aimed to explore experiences of starting CGM virtually. Groups and interviews were audio-recorded, transcribed and analysed using thematic analysis.

RESULTS

Participants were 16 English-speaking parents (age 43 ± 6 years; 63% female) of 15 youth (age 9 ± 4 years; 47% female; 47% non-Hispanic White, 20% Hispanic, 13% Asian, 7% Black, 13% other). They described multiple benefits of the virtual visit including convenient access to high-quality care; integrating Type 1 diabetes care into daily life; and being in the comfort of home. A minority experienced challenges with virtual care delivery; most preferred the virtual format. Participants expressed that clinics should offer a choice of virtual or in-person to families initiating CGM in the future.

CONCLUSION

Most parents appreciated receiving CGM initiation education via telehealth and felt it should be an option offered to all families. Further efforts can continue to enhance CGM initiation teaching virtually to address identified barriers.

Factors Associated with Using Telemedicine in the Primary Care Clinics during the COVID-19 Pandemic in Israel

BACKGROUND

The COVID-19 pandemic generated an extraordinary need for telemedicine.

OBJECTIVE

To identify the factors and multi-way interactions associated with telemedicine use in primary healthcare during the COVID-19 pandemic.

METHODS

This population-based study included all members (2,722,773) aged ≥18 years of the largest healthcare organization in Israel who used primary care clinic services between 1 March 2020 and 31 December 2021. Individuals were classified as telemedicine users (≥1 phone/video visits or asynchronous encounters) or non-telemedicine users (only in-person encounter/s).

RESULTS

Ethnicity was the most discriminative variable associated with telemedicine use, with 85% and 52% users among Jews and Arabs, respectively. Higher odds for telemedicine utilization were observed among women, residents of urban areas, those confined to home, individuals with high level of technology literacy, residents of the central area (in Jews only), young Jews, and older Arabs. Based on decision tree analysis, the segments of the population with the lowest telemedicine use were characterized by lower primary care needs and comorbidities, as well as low technology literacy. The proportion of telemedicine use in these groups was 56% and 27% in Jews and in Arabs, respectively.

CONCLUSION

A proactive intervention program should be applied among populations who are less likely to use telemedicine in the primary care clinics, including Arabs, Jews who live in the distant periphery, and individuals with low technology literacy.

Akhir N, Amin AS, Mohd Shukry ANA, Abdul Rashid MR, Wan Yusof WN. Perceptions of Quality of Life during the Pandemic: A Case Study on B40 Single Mothers

During the pandemic, the lives of B40 single mothers were severely affected, especially in terms of social, economic, and psychological factors. The reduction of income caused by the crisis has forced single mothers and their children to live frugally and without luxury. They also had to perform more than one job at a time during the pandemic to meet their children's needs. A qualitative study has been conducted to explore the perceptions of quality of life during the pandemic among B40 single mothers. Respondents were selected based on demographic characteristics established before the study. A focus group discussion has been conducted on ten (10) B40 single mothers in Balik Pulau, Penang. Single mothers were selected based on purposive sampling. They had to meet the inclusive criteria required to participate in the study, specifically: aged between 20 and 60 years old, belonged to the B40 income category, had children under 18 years old living together, and became single mothers due to divorce or death of husbands. The focused group discussion explored issues related to qualities of life during the pandemic. B40 single mothers expressed their concern about access to health facilities, security in residence, children's education, and economic stability. These areas of life quality have been significantly affected especially during Movement Control Order (MCO). In short, the quality of life of these single mothers has been significantly affected by the pandemic. Their vulnerability towards stress, anxiety, and depression have worsened due to financial issues. Besides the need for emotional and social support, this study found that these single mothers entail financial support.

Impact of Telemedicine on Prenatal Counseling at a Tertiary Fetal Center: A Mixed Methods Study

INTRODUCTION

COVID-19 spurred an unprecedented transition from in-person to telemedicine visits in March 2020 at our institution for all prenatal counseling sessions. This study aims to explore differences in demographics of expectant mothers evaluated pre- and post-telemedicine implementation and to explore the patient experience with telemedicine.

METHODS

A mixed methods study was completed for mothers with a pregnancy complicated by a fetal surgical anomaly who visited a large tertiary fetal center. Using medical records as quantitative data, patient information was collected for all prenatal visits from 3/2019 to 3/2021. The sample was grouped into pre- and post-telemedicine implementation (based on transition date of 3/2020). Univariate analysis was used to compare demographics between the study groups. Statistical significance was defined as P < 0.05. Eighteen semi-structured interviews were conducted from 8/2021 to 12/2021 to explore patients' experiences. Line-by-line coding and thematic analysis was performed to develop emerging themes.

RESULTS

292 pregnancies were evaluated from 3/2019 to 3/2021 (pre-telemedicine 123, post-telemedicine 169). There was no significant difference in self-reported race (P = 0.28), ethnicity (P = 0.46), or primary language (P = 0.98). In qualitative interviews, patients reported advantages to telemedicine, including the convenience of the modality with the option to conduct their session in familiar settings (e.g., home) and avoid stressors (e.g., travel to the medical center and finding childcare). Some women reported difficulties establishing a physician-patient connection and a preference for in-person consultations.

CONCLUSIONS

There was no difference in patient demographics at our fetal center in the year leading up to, and the time following, a significant transition to telemedicine. However, patients had unique perspectives on the advantages and disadvantages of the telemedicine experience. To ensure patient centered care, these findings suggest patient preference should be considered when scheduling outpatient surgical counseling and visits.