A paediatric telecardiology service for district hospitals in south-east England: an observational study

Implementation and Early Experience of a Pediatric Electrophysiology Telehealth Program

Background

Telehealth (TH) visits have been growing with exponential increased utilization during the COVID-19 pandemic. The aim of this manuscript is to describe the implementation and early experience of a pediatric electrophysiology (EP) TH program implemented during the pandemic, assessing patient satisfaction, patient equity and inclusion (measured by geographical outreach), and sustainability.

Methods

A retrospective chart review study was performed and data were collected from the medical record, including demographic, testing, and billing data from scheduled TH encounters between March and August 2020 of a single pediatric EP group in the Midwest. Patients were called to complete satisfaction surveys.

Results

Patients with diverse pathologies were seen in TH, with supraventricular/atrial tachycardias (n = 41, 35%) and inherited arrhythmia syndromes (n = 23, 20%) being most common. The mean distance from clinic was 95 miles (range 2.8–320 miles), with 43% of patients living more than 100 miles away from clinic. A total of 172 tests were performed previsit (n = 102, 59%), during the visit (n = 17, 10%), or postvisit (n = 53, 31%), including 15 EP studies. Time-based Current Procedural Terminology codes were predominantly used for billing purposes (n = 92, 78%). There was generation of work relative value units (wRVU) for visits (220.5 wRVU) and testing (325.1 wRVU). Survey data demonstrated that 98% of patients were satisfied with their telehealth appointment and 99% had a clear understanding of their diagnosis.

Conclusion

Pediatric EP TH clinics can provide care for a geographically and pathologically heterogeneous group of patients who had positive attitudes toward TH. Our study shows significant downstream testing and subsequent wRVU generation, suggesting financial sustainability.

Telecardiology interventions for patients with cardiovascular Disease: A systematic review on characteristics and effects

INTRODUCTION

The prevalence and mortality of cardiovascular diseases are high worldwide. Telecardiology can be used to diagnose and treat these diseases. This paper aimed to review the effectiveness (positive and negative) of implemented telecardiology services in terms of clinical, economic, and patient-reported aspects.

METHODS

A comprehensive search was conducted in Medline (through PubMed), Scopus, ISI web of science, and IEEE Xplore databases from inception to April 7, 2021. the studies that examined the effectiveness of telecardiology interventions were included.

RESULTS

Fifty studies were included in this systematic review. Most investigations (22%) were conducted in the US. In 22% of studies, telecardiology intervention was used for patients with heart failure. Telecardiology has been used in most studies for tele-monitoring (n = 21, 42%) and tele-consultation (n = 17, 34%) and in 29 studies (58%), was applied for ECG transmission. The highest rate of effects reported by studies was clinical. Thirty-five studies (70%) reported the clinical effects; twenty-one studies reported the positive effects for the economic category, and fifteen studies reported the positive effect for patient-reported class. The most positive clinical effects of telecardiology were early diagnosis, early treatment, and mortality reduction. The most positive effect of the economic class was the reduction of health care costs. The most effects of the patient-reported category were improving the patient's quality of life and patient satisfaction.

CONCLUSION

Telecardiology can help early diagnosis and treatment of cardiovascular diseases. It also has great potential in reducing health care costs and increasing quality of life and patient satisfaction.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

Telemedicine: A systematic review of economic evaluations

Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of telemedicine interventions in various specialty areas.

Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were included.

Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology, telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments or cares.

Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.

A retrospective analysis of a pediatric tele-echocardiography service to treat, triage, and reduce trans-Pacific transport

Introduction Tele-echocardiography can ensure prompt diagnosis and prevent the unnecessary transport of infants without critical congenital heart disease, particularly at isolated locations lacking access to tertiary care medical centers. Methods We retrospectively reviewed all infants who underwent tele-echocardiography at a remote 16-bed level IIIB NICU from June 2005 to March 2014. Tele-echocardiograms were completed by cardiac sonographers in Okinawa, Japan, and transmitted asynchronously for review by pediatric cardiologists in Hawaii. Results During the study period 100 infants received 192 tele-echocardiograms: 46% of infants had tele-echocardiograms completed for suspected patent ductus arteriosus, 28% for suspected congenital heart disease, 12% for possible congenital heart disease in the setting of likely pulmonary hypertension, and 10% for possible congenital heart disease in the setting of other congenital anomalies. Of these, 17 patients were aeromedically evacuated for cardiac reasons; 12 patients were transported to Hawaii, while five patients with complex heart disease were transported directly to the United States mainland for interventional cardiac capabilities not available in Hawaii. Discussion This study demonstrates the use of tele-echocardiography to guide treatment, reduce long and potentially risky trans-Pacific transports, and triage transports to destination centers with the most appropriate cardiac capabilities.

Prevalence and diagnostic accuracy of heart disease in children with asymptomatic murmurs

This study was performed to determine the prevalence of CHD among children referred with asymptomatic murmurs and to determine the diagnostic accuracy of the assessment of asymptomatic heart murmurs by general paediatricians. We reviewed the records of children who had been referred by general paediatricians to a cardiology clinic for further evaluation of a heart murmur. The referring paediatricians' clinical assessment of the murmur was compared with the cardiologist's echocardiographic diagnosis. A total of 150 children were referred by paediatricians to a paediatric cardiologist for further assessment of a heart murmur. Out of 150 children, 72 had a paediatrician's diagnosis of innocent murmur; of these 72 patients, two (3%) had heart disease on echocardiography. In all, after echocardiography, a range of congenital heart lesions was found in 28 (19%) of the 150 children. CHD is not rare among children with asymptomatic heart murmurs. In this series of children with asymptomatic murmurs, 19% had heart lesions on echocardiography. Most, but not all, of the children with heart lesions were identified on clinical examination by general paediatricians.

The Cost-Effectiveness of Prenatal Detection for Congenital Heart Disease Using Telemedicine Screening

We estimated the longer-term cost-effectiveness of using telemedicine screening for prenatal detection of congenital heart disease (CHD). One hospital in south-east England with a telemedicine service was connected to a fetal cardiology unit in London. A UK health service perspective was adopted. Evidence on costs and outcomes for standard-risk pregnant women during the antenatal period was based on patient-level data. Extrapolation beyond the end of the study (just after delivery) was carried out for the lifetime of children born with and without CHD. Expert opinion and data from published sources was used to populate a decision model. Future costs and benefits were discounted. The main outcome was quality-adjusted life years (QALYs) and results were expressed as cost per QALY gained. Various one-way sensitivity analyses were conducted. The model showed that offering telemedicine screening by specialists to all standard-risk pregnant women was the dominant strategy (i.e. cheaper and more effective). The sensitivity analyses found that the model was robust, and that telemedicine remained the most cost-effective strategy. The study showed that it would be cost-effective to provide telemedicine examinations as part of an antenatal screening programme for all standard-risk women.

Safety and usefulness of outreach clinic conducted by pediatric echosonographers

Background:

Outreach echocardiographic services led by cardiac sonographers may help district level hospitals in the management of patients suspected to have cardiac anomalies. However, the safety and utility of such an approach is not tested.

Methods:

We retrospectively reviewed our experience of patients seen in the outreach visits by the echocardiographers alone and subsequently reviewed in the pediatric cardiology clinic. Comparison between the diagnosis made by the echocardiographer and the consultant pediatric cardiologist were done. We defined safety as no change in patient management plan between the outreach evaluation and the pediatric cardiology clinic evaluation, and we defined usefulness as being beneficial, serviceable and of practical use.

Results:

Two senior echocardiographic technicians did 41 clinic visits and over a period of 17 months, 623 patients were seen. Patients less than 3 months of age constitute 63% of the total patients seen. Normal echocardiographic examinations were found in 342 (55%) of patients. These patients were not seen in our cardiology clinic. Abnormal echocardiographic examinations were found in 281 (45%) of patients. Among the 281 patients with abnormal echos in the outreach visits, 251 patients (89.3%) were seen in the pediatric cardiology clinic. Comparing the results of the outreach clinic evaluation to that of the pediatric cardiology clinic, 73 patients (29%) diagnosed to have a minor CHD turned to have normal echocardiographic examinations. In all patients seen in both the outreach clinics and the pediatric tertiary cardiac clinics there was no change in patient's management plan.

Conclusions:

Outreach clinic conducted by pediatric echo sonographers could be useful and safe. It may help in reducing unnecessary visits to pediatric cardiology clinics, provide parental reassurance, and help in narrowing the differential diagnosis in critically ill patient unable to be transferred to tertiary cardiac centers provided it is done by experienced echosonographers.

Telemedicine for the support of parents of high-risk newborn infants

BACKGROUND

Telemedicine is the use of electronic communications technology to provide care for patients when distance separates the practitioner and the patient. As the parents and families of infants admitted to the NICU require major support from health professionals in terms of information and time, telemedicine has the potential to increase this support.

OBJECTIVES

To evaluate if the use of telemedicine technology to support families of newborn infants receiving intensive care affects the length of hospital stay and parental/family satisfaction.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2011, Issue 8), MEDLINE (from 1966 to September 2011), EMBASE (1980 to September 2011). We also searched ClinicalTrials.gov (http://www.clinicaltrials.gov) and the EudraCT (http://eudract.emea.eu.int) web sites. We searched the proceedings of conferences of the Canadian Society of Telehealth, American Telemedicine Association, the International Society for Telemedicine, the Annual Conference of The International e-Health Association, American Medical Informatics Association and MedInfo.

SELECTION CRITERIA

We attempted to identify randomised controlled trials that assessed the use of telemedicine designed to support parents of infants cared for in a Neonatal Intensive Care Unit (NICU) compared with standard support measures. Our primary outcome was the length of hospital stay, and secondary outcomes included parental and staff satisfaction, emergency hospital visits post-discharge and family utilisation of infant health-related resources.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies, extracted the data and assessed the risk of bias of the one included study using the standard methods of the Cochrane Neonatal Review Group. We planned to express treatment effects as risk ratio (RR), risk difference (RD), number needed to treat (NNT) and mean difference (MD) where appropriate, using a fixed-effect model.

MAIN RESULTS

A single study was included for analysis in this review. This study compared the use of telemedicine (Baby Carelink) for parents and families of infants in the NICU with a control group without access to this programme and assessed the length of hospital stay for the infants and family satisfaction in multiple components of infant care. The study shows no difference in the length of hospital stay (average length of stay: telemedicine group: 68.5 days (standard deviation (SD) 28.3 days), control group: 70.6 days (SD 35.6 days), MD -2.10 days (95% confidence interval: -18.85 to 14.65 days). There was insufficient information for further analysis of measures of family satisfaction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the use of telemedicine technology to support the parents of high-risk newborn infants receiving intensive care. Clinical trials are needed to assess the application of telemedicine to support parents and families of infants in NICU with length of hospital stay and their perception of NICU care as the major outcomes.

The design of specialist paediatric cardiology telemedicine services to meet the needs of patients

An observational study was conducted of two different videoconferencing services offered by the Royal Brompton and Harefield NHS Trust (RBH), a tertiary centre for cardiology in London. In the first, specialist cardiology advice was provided by telemedicine (384 kbit/s bandwidth) to four district general hospitals in England. In the second, specialist cardiology advice was provided via a low-cost videoconferencing system (128 kbit/s bandwidth) to the Mother and Child Institute in Belgrade. The hospitals chose to use the equipment for different purposes and in different ways. However, at the end of the study, they continued to use telemedicine for the normal provision of clinical services. The success of the projects can be partly attributed to the staff involved and in particular, to the telemedicine champions at the RBH. The needs of the patients were identified and then the telemedicine service was designed by local clinicians to meet those needs.

Costs of neonatal care for low-birthweight babies in English hospitals

AIM

To estimate mean costs of neonatal care for babies with birthweights <or=1800 g in a regional Level 3 unit and three Level 2 units providing short-term intensive care.

METHOD

Babies <or=1800 g admitted to units in four hospitals in England over 15 months in 2001-2002 were audited until discharge. Unit costs (2005-2006 prices) were attributed to their resource items, including neonatal cot occupancy, pharmaceuticals, blood products and ambulance transfers. Bootstrapped mean costs were derived for the Level 3 unit and the Level 2 units combined.

RESULTS

The mean gestation period for 199 Level 3 babies was 29.5 weeks compared with 30.4 weeks for 192 Level 2 babies (p = 0.003). Mean costs excluding ambulance journeys were pound17,861 per Level 3 baby and pound12,344 per Level 2 baby. Level 3 babies <1000 g averaged pound26,815, whereas Level 2 babies <1000 g were generally less costly than babies 1000-1499 g. Ambulances transported 76 Level 3 babies and 62 Level 2 babies; their adjusted mean costs were pound18,495 and pound12,881, respectively.

CONCLUSION

By comprehensively costing resource components, the magnitude of total costs for low-birthweight babies has been revealed, thus demonstrating the importance of budgets for neonatal units being realistically determined by commissioners of neonatal services.

COTS technologies for telemedicine applications

PURPOSE

To demonstrate a simple low-cost system for tele-echocardiology, focused on paediatric cardiology applications.

METHODS

The system was realized using open-source software and COTS technologies. It is based on the transmission of two simultaneous video streams, obtained by direct digitization of the output of an ultrasound machine and by a netcam showing the examination that is taking place. These streams are then embedded into a web page so they are accessible, together with basic video controls, via a standard web browser. The system can also record video streams on a server for further use.

RESULTS

The system was tested on a small group of neonatal cases with suspected cardiopathies for a preliminary assessment of its features and diagnostic capabilities. Both the clinical and technological results were encouraging and are leading the way for further experimentation.

CONCLUSIONS

The presented system can transfer clinical images and videos in an efficient way and in real time. It can be used in the same hospital to support internal consultancy requests, in remote areas using Internet connections and for didactic purposes using low cost COTS appliances and simple interfaces for end users. The solution proposed can be extended to control different medical appliances in those remote hospitals.