Telemedicine

Development of a framework for reporting health service models for managing rheumatoid arthritis

The purpose of this study was to develop a framework for reporting health service models for managing rheumatoid arthritis (RA). We conducted a search of the health sciences literature for primary studies that described interventions which aimed to improve the implementation of health services in adults with RA. Thereafter, a nominal group consensus process was used to synthesize the evidence for the development of the reporting framework. Of the 2,033 citations screened, 68 primary studies were included which described 93 health service models for RA. The origin and meaning of the labels given to these health service delivery models varied widely and, in general, the reporting of their components lacked detail or was absent. The six dimensions underlying the framework for reporting RA health service delivery models are: (1) Why was it founded? (2) Who was involved? (3) What were the roles of those participating? (4) When were the services provided? (5) Where were the services provided/received? (6) How were the services/interventions accessed and implemented, how long was the intervention, how did individuals involved communicate, and how was the model supported/sustained? The proposed framework has the potential to facilitate knowledge exchange among clinicians, researchers, and decision makers in the area of health service delivery. Future work includes the validation of the framework with national and international stakeholders such as clinicians, health care administrators, and health services researchers.

Influence of socioeconomic status on the quality of prescribing in the elderly -- a population based study

AIMS

To compare the quantity and quality of prescribing, using prescribing indicators, between the relatively deprived and the relatively affluent patients over 70 years old in primary care.

METHODS

We examined the General Medical Services (GMS) scheme prescribing data for the Eastern region in Ireland for all patients aged 70 years or more (n = 95 055) during July 2001-December 2002. Prescribing indicators applied to the prescription data to evaluate drugs prescribed to each patient were classified as: (1) descriptive, e.g. number of drug items/patient; (2) indicators assessing potentially harmful prescribing; (3) evidence-based indicators, e.g. secondary prevention therapy in those with ischaemic heart disease (IHD). Results are expressed as odds ratio (OR) and 95% confidence intervals for comparison of prescribing between the relatively deprived and affluent cohorts, adjusted for age and gender (CI) using logistic regression analysis.

RESULTS

The relatively deprived cohort was more likely to receive a greater number of drugs (5.2 vs. 4.5, P < 0.0001), more generic products (P = 0.01) and be exposed to major polypharmacy (> or = five drugs) compared with monotherapy (OR = 1.58; 95% CI = 1.52,1.64, P < 0.0001). They were more likely to receive potentially harmful drugs such as cerebral vasodilators (OR = 1.52; 1.38,1.69), long-acting sulphonylurea (OR = 1.43; 1.20,1.72), potentially interacting agents such as angiotensin converting enzyme (ACE) inhibitor and potassium sparing diuretic (OR = 1.78; 1.48,2.15). In terms of evidence-based prescribing, the relatively deprived cohort with IHD was less likely to receive secondary prevention therapies such as statins (OR = 0.82; 0.74, 0.90) and beta blockers (OR = 0.85; 0.77,0.93).

CONCLUSIONS

These results show that suboptimal prescribing is more prevalent among the relatively deprived cohort and suggests the differences observed in the quality of prescribing between these patient groups may be related to their socioeconomic status.

Evaluation of the effectiveness of portable low-bandwidth telemedical applications for postoperative followup: initial results

BACKGROUND

The idea of using telemedical applications to evaluate patients remotely is several decades old. It has already been established that x-ray images (and magnetic resonance images) can be transferred using a personal computer and a modem, and many other such applications have been implemented. Over the past 50 years the expense and technical demands of the equipment involved in telemedicine have hindered its widespread deployment. The purpose of this study is to evaluate the ability of a mobile, low-bandwidth telemedicine platform to achieve real-time postoperative visits in the home.

STUDY DESIGN

This evaluation was designed to evaluate the feasibility of performing a real-time clinical visit with computer and telecommunications hardware and software. A nurse and medical student (for information gathering only) made postoperative visits at patients' homes while the physician stayed at the office. Clinical evaluations were performed by using low-resolution and frame-rate video, high-resolution still images, and simultaneous telephony over a standard telephone line. These remote visits were followed by a standard visit in the office. Eleven patients were included, all of whom had undergone various laparoscopic procedures. They lived 5 to 240 miles from their surgeon. Efficiency was measured by recording the time required to capture and send data required by the physician to make a clinical decision. The time expense was measured at both the patients' and physician's locations. Technical issues were evaluated and patient satisfaction was assessed by standardized objective questionnaires. The accuracy of the evaluation at the remote visit was determined with a standard office visit.

RESULTS

No technical problems were observed. The mean total time of the housecall at the remote site was 86 minutes (range 60 to 160 minutes) and at the base station site was 41 minutes (range 21 to 71 minutes). After personnel became familiar with the system, the last three visits averaged 61 and 25 minutes at the two sites, respectively. This corresponds favorablywith current time requirements for visiting nurses and office visits. The patients were highly satisfied with the home visit and, on average, rated the experience as 4.8 out of a maximum of 5.

CONCLUSIONS

Followup visits in patients' homes after laparoscopic procedures can be accomplished by transmitting simultaneous voice, low-resolution video, and high-resolution still images to accurately perform postoperative evaluations over standard telephone lines, with time requirements and clinical accuracy similar to those of standard visits.

Use of mobile low-bandwith telemedical techniques for extreme telemedicine applications

BACKGROUND

Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world.

STUDY DESIGN

Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine.

RESULTS

Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps.

CONCLUSIONS

Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.