Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

The financial impact and utilization of inpatient dermatology services: historical insights and future implications

Skin diseases affect millions of Americans, imposing a large financial burden on the U.S. healthcare system annually. Inpatient dermatology is a subspecialty focused on treating complicated skin diseases in hospitalized patients. Utilization of these services enhances diagnostic accuracy, shorten hospital stays, lower readmission rates, and improve patient outcomes. However, studies have indicated an overall decline in inpatient dermatology consultations and dermatology as primary admitting services. Currently, only two academic hospitals in the United States grant dermatologists admitting privileges, indicating decreased exposure to inpatient dermatology in residency despite the need for more hospital-based dermatologists. Therefore, this narrative review aims to characterize the financial impact and utilization of inpatient dermatology services. Historical and recent data consistently highlight the financial benefit of dermatologic hospitalizations and poor utilization of inpatient dermatology consultations. Teledermatology consultations also improve diagnostic accuracy and expedite interventions to improve patient outcomes. However, challenges like reduced reimbursement, lack of protocols, and limited resident training in inpatient dermatology have discouraged dermatologists from providing inpatient consultations. Policy changes are needed to promote these services that benefit patients as well as health systems.

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.

Usefulness of digital measurements for functional evaluation of paediatric elbow range of motion

BACKGROUND

Elbow immobilization due to fractures of the upper limb is frequent in paediatric patients. Proper follow-up is critical to assess elbow functional recovery. Telemedicine can be an option for remote monitoring of these patients. The purpose of this study was to compare personal and virtual evaluation of elbow range of motion after long arm cast withdrawal in paediatric patients.

METHODS

An observational cross-sectional study was carried out which included all paediatric patients with elbow immobilization in long arm casts treated at our centre. After cast withdrawal, elbow range of motion was evaluated by telemedicine and in office consultation in all four movements (flexion, extension, pronation and supination).

RESULTS

Ninety-three patients met the selection criteria. Median age at time of immobilization was 8 years. Mean elbow immobilization time was 23 days (range 18-56 days). When comparing office and remote measurements, no statistical differences were found for any of the four elbow movements measured in our study.

CONCLUSIONS

Remote evaluation of elbow range of motion by telemedicine is technically feasible. We evaluated elbow range of motion in paediatric patients after immobilization and we did not find differences between digital and in office measurements. The results were similar to those obtained through assessment in the office. We believe that this is a useful tool to facilitate remote patient follow-up.

Post-COVID-19: can digital solutions lead to a more equitable global healthcare workforce?

An unintended consequence of the COVID-19 pandemic has been the exponential growth of telemedicine, with automation of healthcare becoming more common. Face-to-face meetings and training events have been replaced relatively seamlessly with online versions, taking clinical or academic expertise to distant parts of the world and making them more accessible and affordable. The wide reach of digital platforms offering remote healthcare offers the opportunity of democratising access to high-quality healthcare, However, certain challenges remain: (a) clinical guidance developed in one geographical area may need adaptation for use in others; (b) regulatory mechanisms from one jurisdiction need to offer patient safety across other jurisdictions; (c) barriers created by disparity in technology infrastructure and the variation in pay for services across different economies, leading to brain drain and an inequitable workforce. The World Health Organization's Global Code of Practice on the International Recruitment of Health Personnel could offer the preliminary framework on which solutions to these challenges could be built.

Reliability of a human pose tracking algorithm for measuring upper limb joints: comparison with photography-based goniometry

BACKGROUND

Range of motion (ROM) measurements are essential for diagnosing and evaluating upper extremity conditions. Clinical goniometry is the most commonly used methods but it is time-consuming and skill-demanding. Recent advances in human tracking algorithm suggest potential for automatic angle measuring from RGB images. It provides an attractive alternative for at-distance measuring. However, the reliability of this method has not been fully established. The purpose of this study is to evaluate if the results of algorithm are as reliable as human raters in upper limb movements.

METHODS

Thirty healthy young adults (20 males, 10 females) participated in this study. Participants were asked to performed a 6-motion task including movement of shoulder, elbow and wrist. Images of movements were captured by commercial digital cameras. Each movement was measured by a pose tracking algorithm (OpenPose) and compared with the surgeon-measurement results. The mean differences between the two measurements were compared. Pearson correlation coefficients were used to determine the relationship. Reliability was investigated by the intra-class correlation coefficients.

RESULTS

Comparing this algorithm-based method with manual measurement, the mean differences were less than 3 degrees in 5 motions (shoulder abduction: 0.51; shoulder elevation: 2.87; elbow flexion:0.38; elbow extension:0.65; wrist extension: 0.78) except wrist flexion. All the intra-class correlation coefficients were larger than 0.60. The Pearson coefficients also showed high correlations between the two measurements (p < 0.001).

CONCLUSIONS

Our results indicated that pose estimation is a reliable method to measure the shoulder and elbow angles, supporting RGB images for measuring joint ROM. Our results presented the possibility that patients can assess their ROM by photos taken by a digital camera.

TRIAL REGISTRATION

This study was registered in the Clinical Trials Center of The First Affiliated Hospital, Sun Yat-sen University (2021-387).

Primary care consultations for respiratory tract symptoms during the COVID-19 pandemic: a cohort study including 70,000 people in South West England

BACKGROUND

Primary care consultations for respiratory tract symptoms including identifying and managing COVID-19 during the pandemic have not been characterized.

METHODS

A retrospective cohort analysis using routinely collected records from 70,431 adults aged 18+ in South England within the Electronic Care and Health Information Analytics (CHIA) database. Total volume and type of consultations (face-to-face, home visits, telephone, email/video, or out of hours) for respiratory tract symptoms between 1 January and 31 July 2020 (during the first wave of the pandemic) were compared with the equivalent period in 2019 for the same cohort. Descriptive statistics were used to summarize consultations by sociodemographic and clinical characteristics, and by COVID-19 diagnosis and outcomes (death, hospitalization, and pneumonia).

RESULTS

Overall consultations for respiratory tract symptoms increased by 229% during the pandemic compared with the preceding year. This included significant increases in telephone consultations by 250%, a 1,574% increase in video/email consultations, 105% increase in home visits, and 92% increase in face-to-face consultations. Nearly 60% of people who presented with respiratory symptoms were tested for COVID-19 and 16% confirmed or clinically suspected to have the virus. Those with complications including pneumonia, requiring hospitalization, and who died were more likely to be seen in-person.

CONCLUSION

During the pandemic, primary care substantially increased consultations for respiratory tract symptoms to identify and manage people with COVID-19. These findings should be balanced against national reports of reduced GP workload for non-COVID care.

Orthopedic Telemedicine Outpatient Practice Diagnoses Set during the First COVID-19 Pandemic Lockdown-Individual Observation

The COVID-19 pandemic has caused a substantial intensification of the telemedicine transformation process in orthopedics since 2020. In the light of the legal regulations introduced in Poland, from the beginning of the SARS-CoV-2 pandemic, physicians, including orthopedic surgeons, have had the opportunity to conduct specialist teleconsultations. Teleconsultations increase epidemiological safety and significantly reduce the exposure of patients and medical staff to direct transmission of the viral vector and the spread of infections. The study aimed to describe diagnoses and clinical aspects of consecutive orthopedic teleconsultations (TC) during the pandemic lockdown. The diagnoses were set according to the International Classification of Diseases (ICD-10). Hybrid teleconsultations used smartphones and obligatory Electronic Health Record (EHR) with supplemental voice, SMS, MMS, Medical images, documents, and video conferencing if necessary. One hundred ninety-eight consecutive orthopedic teleconsultations were served for 615 women and 683 men (mean age 41.82 years ± 11.47 years). The most frequently diagnosed diseases were non-acute orthopedic disorders "M" (65.3%) and injuries "S" (26.3%). Back pain (M54) was the most frequent diagnosis (25.5%). Although virtual orthopedic consultation cannot replace an entire personal visit to a specialist orthopedic surgeon, in many cases, teleconsultation enables medical staff to continue to participate in providing medical services at a sufficiently high medical level to ensure patient and physician. The unified approach to TC diagnoses using ICD-10 or ICD-11 may improve further research on telemedicine-related orthopedics repeatability. Future research directions should address orthopedic teleconsultations' practical aspects and highlight legal, organizational, and technological issues with their implementations.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care

Objectives

Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care.

Methods

A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment.

Results

Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded "yes" to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor's diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%).

Conclusion

This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Implementing video visits into an orthopedic hip arthroscopy practice: a case study

Telehealth videoconferencing has been shown to be feasible, cost-effective and safe in numerous fields of medicine. In an effort to increase access and improve the quality of care offered to patients we implemented a telehealth initiative allowing for remote orthopedic clinic visits at a major academic medical center. Here we report on our experience and early outcomes. A telehealth platform was launched for a single fellowship trained orthopedic surgeon at a major academic hospital in August 2018. New patients residing outside the metro area, all return patients and patients with an uncomplicated post-operative course were offered the option to complete patient encounters remotely via a telehealth platform. Each patient was offered a Patient Satisfaction Survey following video visit. Patient zip codes were used to estimate patient commutes. Ninety-six percent of patients agreed/strongly agreed with the statement 'I was satisfied with my Telehealth experience' while 51% agreed/strongly agreed with the statement 'This visit was just as good as a face to face visit'. In all, 94% of patients agreed/strongly agreed with the statement 'Having a telehealth visit made receiving care more accessible for me'. The median miles saved on commutes were 123.3 miles. The no show rate for telehealth visits was 8.2% versus 3.2% for in-person (P < 0.001). Telehealth video visits provided patients with a modality for completing orthopedic clinic visits while maintaining a high-quality care and patient satisfaction. Patient convenience was optimized with video visits with elimination of long commutes. Level of evidence: IV.

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology

HYPOTHESIS/BACKGROUND

In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE.

METHODS

The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test.

RESULTS

We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87).

CONCLUSION

This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

The Use of Patient-Facing Teleconsultations in the National Health Service: Scoping Review

BACKGROUND

The National Health Service (NHS) Long-Term Plan has set out a vision of enabling patients to access digital interactions with health care professionals within 5 years, including by video link.

OBJECTIVE

This review aimed to examine the extent and nature of the use of patient-facing teleconsultations within a health care setting in the United Kingdom and what outcome measures have been assessed.

METHODS

We conducted a systematic scoping review of teleconsultation studies following the Joanna Briggs Institute methodology. PubMed, Scopus, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were searched up to the end of December 2018 for publications that reported on the use of patient-facing teleconsultations in a UK health care setting.

RESULTS

The search retrieved 3132 publications, of which 101 were included for a full review. Overall, the studies were heterogeneous in design, in the specialty assessed, and reported outcome measures. The technology used for teleconsultations changed over time with earlier studies employing bespoke, often expensive, solutions. Two-thirds of the studies, conducted between 1995 and 2005, used this method. Later studies transitioned to Web-based commercial solutions such as Skype. There were five outcome measures that were assessed: (1) technical feasibility, (2) user satisfaction, (3) clinical effectiveness, (4) cost, (5) logistical and operational considerations. Due to the changing nature of technology over time, there were differing technical issues across the studies. Generally, teleconsultations were acceptable to patients, but this was less consistent among health care professionals. However, among both groups, face-to-face consultations were still seen as the gold standard. A wide range of clinical scenarios found teleconsultations to be clinically useful but potentially limited to more straightforward clinical interactions. Due to the wide array of study types and changes in technology over time, it is difficult to draw definitive conclusions on the cost involved. However, cost savings for health care providers have been demonstrated by the goal-directed implementation of teleconsultations. The integration of technology into routine practice represents a complex problem with barriers identified in funding and hospital reimbursement, information technologies infrastructure, and integration into clinicians' workflow.

CONCLUSIONS

Teleconsultations appear to be safe and effective in the correct clinical situations. Where offered, it is likely that patients will be keen to engage, although teleconsultations should only be offered as an option to support traditional care models rather than replace them outright. Health care staff should be encouraged and supported in using teleconsultations to diversify their practice. Health care organizations need to consider developing a digital technology strategy and implementation groups to assist health care staff to integrate digitally enabled care into routine practice. The introduction of new technologies should be assessed after a set period with service evaluations, including feedback from key stakeholders.

Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Background

Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain.

Objective

This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care.

Methods

A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis.

Results

This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes.

Conclusions

E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

Remote Assessment of Wrist Range of Motion: Inter- and Intra-Observer Agreement of Provider Estimation and Direct Measurement With Photographs and Tracings

PURPOSE

Information is limited regarding the validity and reliability of measurements made during remote assessment of wrist range of motion (ROM) motion. We sought to determine intra- and inter-observer agreement among visual estimation, direct goniometric measurement, and patients' self-taken digital photographs and line tracings by comparing the degree differences among measurements. We hypothesized that inter- and intra-observer differences would be less than 10° at least 90% of the time for all measurement modalities.

METHODS

Thirty-seven patients were enrolled in this prospective cohort study. Visual estimation immediately followed by direct goniometry of maximal active wrist ROM (extension [E], flexion [F], radial deviation, and ulnar deviation) were independently and blindly assessed by 3 different providers: a hand surgeon, a hand therapist, and an orthopedic resident. Self-taken photographs and line tracings were blindly evaluated 3 weeks later. Intra- and inter-observer agreement was described using the Bland-Altman method.

RESULTS

The surgeon and hand therapist observed intra-observer agreement within 10° for visual estimation of all 4 directions of motions greater than 90% of the time, but inter-observer agreement for E/F was lower (76% to 86%). Intra-observer agreement by the resident was within 10° 78% of the time for E/F. Intra-observer agreement for photographs and tracings were lower than visual estimation for all observers. Inter-observer agreement for photographs and tracings was higher than intra-observer agreement. The surgeon and hand therapist agreed within 10° at least 76% of the time, the surgeon and resident agreed within 10° at least 62% of the time, and the hand therapist and resident agreed within 10° at least 54% of the time.

CONCLUSIONS

Visual estimation may be a valid method of remote assessment, but compared with goniometry, measurements may be susceptible to observer bias. Self-taken photographs and line tracings are unreliable, perhaps falsely lower owing to submaximal effort from task distraction, and we question their current use for remote assessment of wrist ROM.

CLINICAL RELEVANCE

These results represent an initial step in evaluating potential methods of remote assessment of wrist ROM.

Patient preferences on the use of technology in cancer surveillance after curative surgery: A cross-sectional analysis

BACKGROUND

Advances in communication technology have enabled new methods of delivering test results to cancer survivors. We sought to determine patient preferences regarding the use of newer technology in delivering test results during cancer surveillance.

METHODS

A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication versus phone call or office visit) to receive surveillance test results was undertaken.

RESULTS

Among 257 respondents, the average age was 59.1 years (SD 13.5) and 61.8% were female. Common malignancies included melanoma/sarcoma (29.5%), thyroid (25.7%), breast (22.8%), and gastrointestinal (22.0%) cancer. Although patients expressed a relative preference to receive normal surveillance results via MyChart or secure e-mail, the majority preferred abnormal imaging (87.2%) or blood results (85.9%) to be communicated by in-office appointments or phone calls irrespective of age or cancer type. Patients with a college degree or higher were more likely to prefer electronic means of communication of abnormal blood results compared with a telephone call or in-person visit (odds ratio 2.18, 95% confidence interval: 1.01-4.73, P < .05). In contrast, patients >65 years were more likely to express a preference for telephone or in-person communication of normal imaging results (odds ratio: 2.03, 95% CI: 1.16-3.56, P < .05) versus patients ≤65 years. Preference also varied according to malignancy type.

CONCLUSION

Although many cancer patients preferred to receive "normal" surveillance results electronically, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial

BACKGROUND

Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs.

OBJECTIVE

The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away.

METHODS

An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results.

RESULTS

This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183.

CONCLUSIONS

This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Video clinics versus standard face-to-face appointments for liver transplant patients in routine hospital outpatient care: study protocol for a pragmatic randomised evaluation of myVideoClinic

Background

Video clinics, where patients can have a hospital appointment with their clinician from home, are emerging in practice, but their effectiveness is unclear. This study will evaluate whether a video clinic implemented at the University Hospitals Birmingham (UHB) NHS Foundation Trust improves patient satisfaction compared to standard face-to-face appointments for liver transplant patients.

Methods

This will be a parallel, two-arm, statistician-blinded, randomised evaluation. Clinically stable liver patients at 1 to 5 years post-transplant (n = 180) will be randomised in equal numbers to video clinic appointments (intervention) or standard face-to-face appointments (control). The intervention group will have outpatient appointments from home via a secure video link accessed through the UHB patient portal. All patients will complete baseline questionnaires before randomisation and electronic follow-up questionnaires after each follow-up appointment during the subsequent 12 months. The primary outcome is the difference in scores between groups for three domains of patient satisfaction, namely ‘convenience of location’, ‘getting through to the office by phone’ and ‘length of time waiting’ (modified Visit-Specific Satisfaction Instrument). Secondary outcomes include quality of life (EQ-5D-5 L), costs, clinical contacts and user experience. Statistical analysis will be descriptive and performed on an intention-to-treat basis. The primary outcome will be analysed using baseline and 3-, 6-, 9- and 12-month questionnaires (according to patient follow-up appointment frequency) and comparisons made between study arms. A within-trial cost consequences analysis will be undertaken on the economic data. Patients (n = 8), carers/family members (n = 6) and health professionals (n = 14) will be interviewed about the experience of video clinics and the interviews will be analysed using thematic analysis.

Discussion

This study will allow an in depth understanding of whether video clinics can improve patient satisfaction with their care. In addition, the intervention could save patients time and costs, removing the need to travel long distances for outpatient appointments. Video clinics may be applicable to a wide range of other clinical settings and health conditions. The study has been approved by the NHS Health Research Authority and a National Research Ethics Committee (Ref: 17/WM/0338) and research governance approval has been obtained from UHB (Ref: RRK6080).

Trial registration

ISRCTN: 14093266 (25/03/2018; retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2953-4) contains supplementary material, which is available to authorized users.

Telemedicine utilisation in a paediatric sports medicine practice: decreased cost and wait times with increased satisfaction

Objectives

Telemedicine is the use of telecommunication to provide healthcare remotely. We sought to quantify time/cost savings and satisfaction between a cohort of telemedicine and inperson visits in a tertiary paediatric orthopaedic clinic.

Methods

Time for clinical visits and wait times were compared between telemedicine and inperson visits. Costs to patients and department were also calculated for both visit types. Parents completed a five-item satisfaction survey regarding their telemedicine experience.

Results

Visit times (15 vs 68 min, P<0.001) and wait times (2 vs 33 min, P<0.001) were shorter for telemedicine visits. Families saved 85 miles of driving and $50 in costs per telemedicine visit. Labour cost saved for a telemedicine visit was $24/patient. More than 90% of patients were satisfied with the telemedicine service.

Conclusion

Telemedicine can be used in a sports medicine setting to provide care that reduces costs while maintaining high levels of patient satisfaction.

Level of evidence

Level III.

Prospective evaluation of a virtual urology outpatient clinic

BACKGROUND

Outpatient department (OPD) clinics account for a significant proportion of healthcare expenditure. We report on a pilot study of a virtual outpatient clinic (VC) for urology patients as an alternative to a general urology clinic review.

AIMS

The study aims to assess the safety and cost-effectiveness of a virtual clinic as an alternative to general OPD review.

METHODS

A prospective study performed between March 2015 and December 2015 investigated the effectiveness of a VC in our institution. Eligible patients were recruited from general urology outpatient visits, from medical team members and from general practitioners (GP). Data recorded on each VC review included patient demographics, indication for referral to VC, outcome of VC and method of communication with the patient and their GP after the VC.

RESULTS

Three hundred eighty-five patients were registered for the VC. Indications for referral included review of imaging results (n = 136), doctor or patient query (n = 112) and review of laboratory results (n = 67). Outcomes after VC review included general OPD follow-up (n = 134), discharge from urology care (n = 39), referral for urological intervention (n = 29) and referral for radiological investigation (n = 23). VC review prevented 217 OPD clinic visits, saved €17,360 and provided a failsafe mechanism for reviewing investigation results. Two patients booked for OPD review following VC review did not receive appointments.

CONCLUSIONS

Virtual clinic is a safe and cost-effective alternative to general OPD review in appropriately selected patients.

eConsultations to Infectious Disease Specialists: Questions Asked and Impact on Primary Care Providers' Behavior

BACKGROUND

Since 2010, the Champlain BASE (Building Access to Specialist Advice through eConsultation) has allowed primary care providers (PCPs) to submit clinical questions to specialists through a secure web service. The study objectives are to describe questions asked to Infectious Diseases specialists through eConsultation and assess impact on physician behaviors.

METHODS

eConsults completed through the Champlain BASE service from April 15, 2013 to January 29, 2015 were characterized by the type of question asked and infectious disease content. Usage data and PCP responses to a closeout survey were analyzed to determine eConsult response time, change in referral plans, and change in planned course of action.

RESULTS

Of the 224 infectious diseases eConsults, the most common question types were as follows: interpretation of a clinical test 18.0% (41), general management 16.5 % (37), and indications/goals of treating a particular condition 16.5% (37). The most frequently consulted infectious diseases were as follows: tuberculosis 14.3% (32), Lyme disease 14.3% (32), and parasitology 12.9% (29). Within 24 hours, 63% of cases responded to the questions, and 82% of cases took under 15 minutes to complete. In 32% of cases, a face-to-face referral was originally planned by the PCP but was no longer needed. In 8% of cases, the PCP referred the patient despite originally not planning to make a referral. In 55% of cases, the PCP either received new information or changed their course of action.

CONCLUSIONS

An eConsult service provides PCPs with timely access to infectious disease specialists' advice that often results in a change in plans for a face-to-face referral.

Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review

We undertook a scoping review of the published literature to identify and summarise key findings on the telehealth interventions that influence waiting times or waiting lists for specialist outpatient services. Searches were conducted to identify relevant articles. Articles were included if the telehealth intervention restructured or made the referral process more efficient. We excluded studies that simply increased capacity. Two categories of interventions were identified - electronic consultations and image-based triage. Electronic consultations are asynchronous, text-based provider-to-provider consultations. Electronic consultations have been reported to obviate the need for face-to-face appointments between the patient and the specialist in between 34-92% of cases. However, it is often reported that electronic consultations are appropriate in less than 10% of referrals for outpatient care. Image-based triage has been used successfully to reduce unnecessary or inappropriate referrals and was used most often in dermatology, ophthalmology and otolaryngology (ENT). Reported reduction rates for face-to-face appointments by specialty were: dermatology 38-88%, ophthalmology 16-48% and ENT 89%. Image-based triage can be twice as effective as non-image based triage in reducing unnecessary appointments. Telehealth interventions can effectively be used to reduce waiting lists and improve the coordination of specialist services, and should be considered in conjunction with clinical requirements.

Opportunity cost of the dermatologist's consulting time in the economic evaluation of teledermatology

Introduction This study, through a systematic review and meta-analysis, has sought to demonstrate that the opportunity cost is a value to take into account in studies of economic cost in telemedicine, illustrated through the time of the dermatologist's consultation in teledermatology and traditional consultation. Methods Economic evaluation studies have been identified that compare teledermatology and traditional dermatological consultation during the period 1998-2015. We carried out a meta-analysis considering the work cost and the dermatologist's consultation time, analysing their differences. The opportunity cost represented by these differences in the dermatological remote consultation time was subsequently calculated based on the design of a cost/time variable. Results It was not possible to meta-analyse the cost of the dermatologist's consultation due to insufficient standardized complete data. It was possible to carry out a meta-analysis of the consultation time, and three articles were selected (2945 patients). Teledermatology accounts for more time (7.54 min) than conventional consultation ( p < 0.00001) and this difference is an opportunity cost of teledermatology of €29.25 per each remote consultation, with a unitary factor cost/time of 3.88€/minute. Conclusions There is no unanimity in the literature regarding which of the two procedures is cheaper; further studies with the necessary standardized variables are required. In this meta-analysis, teledermatology takes more time than a conventional dermatology consultation, which leads to an opportunity cost, increasing the total cost of consultation. The opportunity cost is a value that should be included in an analysis of economic costs, in the context of an economic assessment, when we evaluate a health activity.

A prospective randomized controlled study of a virtual clinic integrating primary and specialist care for patients with Type 2 diabetes mellitus

AIMS

To investigate the effectiveness of a diabetes virtual clinic to enhance diabetes in primary care by developing clinical management plans for patients with suboptimal metabolic control and/or case complexity.

METHODS

A prospective study with randomized allocation to virtual clinic or usual care. Patients with Type 2 diabetes (n = 208) were recruited from six general practices in South London. The primary outcome for the study was glycaemic control, secondary outcomes included: lipids, blood pressure, weight (kg and BMI) and renal function (eGFR). Data were collected from participants' records at baseline and 12 months. We also considered process measures including therapy optimization.

RESULTS

The 12-month data show equivalence between the virtual clinic and control groups for glycaemic control with both achieving clinically significant reductions in HbA1c of 8 mmol/mol (0.6 ± 1.7%) and 10 mmol/mol (0.8 ± 1.9%), respectively (P = 0.4). The virtual clinic group showed superiority over the intervention group for blood pressure control with a mean reduction in systolic blood pressure of 6 ± 16 mmHg compared with an increased of 2 ± 18 mmHg in the control group (P = 0.008). There were no significant differences between the groups in terms of cholesterol, weight and renal function. Process measures showed an increased level of therapy adjustment in the virtual clinic group.

CONCLUSION

The virtual clinic model explored in this study showed a clinically important improvement in glycaemic control. Although this improvement was not superior to that observed in the control participants, this might be attributable to the systemic impact of the virtual clinic on the practice as a whole.

Acceptability, Feasibility, and Cost of Telemedicine for Nonacute Headaches: A Randomized Study Comparing Video and Traditional Consultations

Background

The feasibility of telemedicine in diagnosing and treating nonacute headaches, such as primary headaches (migraine and tension-type) and medication-overuse headaches has not been previously investigated. By eliminating the need of travel to specialists, telemedicine may offer significant time and money savings.

Objectives

Our objective was to estimate the acceptance of telemedicine and investigate the feasibility and cost savings of telemedicine consultations in diagnosing and treating nonacute headaches.

Methods

From September 2012 to March 2015, nonacute headache patients from Northern Norway who were referred to neurologists through an electronic application system were consecutively screened and randomized to participate in either telemedicine or traditional specialist visits. All patients were consulted by two neurologists at the neurological department in Tromsø University Hospital. Feasibility outcomes were compared between telemedicine and traditional groups. Baseline characteristics and costs were then compared between rural and urban patients. Travel costs were calculated by using the probabilistic method of the Norwegian traveling agency: the cheapest means of public transport for each study participant. Loss of pay was calculated based on the Norwegian full-time employee’s average salary: < 3.5 hours=a half day’s salary, > 3.5 hours spent on travel and consultation=one day’s salary. Distance and time spent on travel were estimated by using Google Maps.

Results

Of 557 headache patients screened, 479 were found eligible and 402 accepted telemedicine participation (83.9%, 402/479) and were included in the final analyses. Of these, 202 received traditional specialist consultations and 200 received telemedicine. All patients in the telemedicine group were satisfied with the video quality, and 198 (99%, 198/200) were satisfied with the sound quality. The baseline characteristics as well as headache diagnostics and follow-up appointments, and the investigation, advice, and prescription practices were not statistically different between the two randomized groups. In addition, telemedicine consultations were shorter than traditional visits (38.8 vs 43.7 min, P<.001).

The travel cost per rural individual (292/402, 73%) was €249, and estimated lost income was €234 per visit. The travel cost in the urban area (110/402, 27%) was €6, and estimated lost income was €117 per visit. The median traveling distance for rural patients was 526 km (range 1892 km), and the median traveling time was 7.8 hours (range 27.3 hours). Rural patients had a longer waiting time than urban patients (64 vs 47 days, P=.001), and fewer women were referred from rural areas (P=.04). Rural women reported higher pain scores than urban women (P=.005).

Conclusion

Our study shows that telemedicine is an accepted, feasible, time-saving, and cost-saving alternative to traditional specialist consultations for nonacute headaches.

Trial Registration

Clinicaltrials.gov NCT02270177; http://clinicaltrials.gov/ct2/show/NCT02270177 (Archived by WebCite at http://www.webcitation.org/6hmoHGo9Q)

E-consulting in a medical specialist setting: Medicine of the future?

OBJECTIVE

Today's technology provides new ways of consulting between patients and medical specialists in health care, such as videoconferencing and web-messaging. In this systematic review we assessed the effects of e-consulting between medical specialists and patients.

METHODS

We searched MEDLINE, EMBASE, Psychlit and Cochrane Library for randomized clinical trials assessing the use of e-consulting methods (videoconferencing (VC) or web-messaging (WM)), as compared to conventional care (face-to-face (FF) or telephone consultations (TC)) in a medical specialist setting. We extracted patient-related, physician-related, cost, time and follow-up outcomes.

RESULTS

We included 21 trials, of which 17 addressed VC compared to FF, two compared WM with FF, one VC with TC, and one WM with TC. Physicians appeared to prefer face-to-face consultations over videoconferencing. Patients appeared to be as satisfied with videoconferencing as with face-to-face contacts, but preferred videoconferencing and web-messaging over telephone consultations. Videoconferencing was more expensive regarding equipment, but saved patient-related costs in terms of time, transportation, and missed work. Variable results were found for consult time and follow-up visits.

CONCLUSIONS AND PRACTICE IMPLICATIONS

We cautiously conclude that e-consulting seems a feasible alternative to medical specialists' face-to-face follow-up or telephone appointments, but may be less suitable for initial consultations requiring physical examination.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

The association between general practitioner participation in joint teleconsultations and rates of referral: a discrete choice experiment

Background

Joint consultations – such as teleconsultations – provide opportunities for continuing education of general practitioners (GPs). It has been reported this form of interactive case-based learning may lead to fewer GP referrals, yet these studies have relied on expert opinion and simple frequencies, without accounting for other factors known to influence referrals. We use a survey-based discrete choice experiment of GPs’ referral preferences to estimate how referral rates are associated with participation in joint teleconsultations, explicitly controlling for a number of potentially confounding variables.

Methods

We distributed questionnaires at two meetings of the Portuguese Association of General Practice. GPs were presented with descriptions of patients with dermatological lesions and asked whether they would refer based on the waiting time, the distance to appointment, and pressure from patients for a referral. We analysed GPs’ responses to multiple combinations of these factors, coupled with information on GP and practice characteristics, using a binary logit model. We estimated the probabilities of referral of different lesions using marginal effects.

Results

Questionnaires were returned by 44 GPs, giving a total of 721 referral choices. The average referral rate for the 11 GPs (25%) who had participated in teleconsultations was 68.1% (range 53-88%), compared to 74.4% (range 47-100%) for the remaining physicians. Participation in teleconsultations was associated with reductions in the probabilities of referral of 17.6% for patients presenting with keratosis (p = 0.02), 42.3% for psoriasis (p < 0.001), 8.4% for melanoma (p = 0.14), and 5.4% for naevus (p = 0.19).

Conclusions

The results indicate that GP participation in teleconsultations is associated with overall reductions in referral rates and in variation across GPs, and that these effects are robust to the inclusion of other factors known to influence referrals. The reduction in range, coupled with different effects for different clinical presentations, may suggest an educational effect. However, more research is needed to establish whether there are causal relationships between participation in teleconsultations, continuing education, and referral rates.

Efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial

BACKGROUND

Telemedicine in an ambulatory surgical population remains incompletely evaluated.

OBJECTIVE

To investigate patient encounters in the outpatient setting using video visit (VV) technology compared to traditional office visits (OVs).

DESIGN, SETTING, AND PARTICIPANTS

From June 2013 to March 2014, 55 prescreened men with a history of prostate cancer were prospectively randomized. VVs, with the patient at home or at work, were included in the outpatient clinic calendar of urologists.

INTERVENTION

Remote VV versus traditional OV.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

An equivalence analysis was used to assess the primary outcome, visit efficiency as measured by time studies. Secondary outcomes were patient/provider satisfaction and costs.

RESULTS AND LIMITATIONS

There were 28 VVs and 27 OVs. VVs were equivalent in efficiency to relative to OVs, as measured by patient-provider face time (mean 14.5 vs 14.3min; p=0.96), patient wait time (18.4 vs 13.0min; p=0.20), and total time devoted to care (17.9 vs 17.8min; p=0.97). There were no significant differences in patient perception of visit confidentiality, efficiency, education quality, or overall satisfaction. VVs incurred lower costs, including distance traveled (median 0 vs 95 miles), travel time (0 vs 95min), missed work (0 vs 1 d), and money spent on travel ($0 vs $48; all p<0.0001). There was a high level of urologist satisfaction for both VVs (88%) and OVs (90%). The major limitation was sample size.

CONCLUSIONS

VV in the ambulatory postprostatectomy setting may have a future role in health care delivery models. We found equivalent efficiency, similar satisfaction, but significantly reduced patient costs for VV compared to OV. Further prospective analyses are warranted.

PATIENT SUMMARY

Among men with surgically treated prostate cancer, we evaluated the utility of remote video visits compared to office visits for outpatient consultation with a urologist. Video visits were associated with equivalent efficiency, similar satisfaction, and significantly lower patient costs when compared to office visits. We conclude that video visits may have a future role in health care delivery models.

Access to Specialist Care in Rural Saskatchewan: The Saskatchewan Rural Health Study

The role of place has emerged as an important factor in determining people’s health experiences. Rural populations experience an excess in mortality and morbidity compared to those in urban settings. One of the factors thought to contribute to this rural-urban health disparity is access to healthcare. The objective of this analysis was to examine access to specialized medical care services and several possible determinants of access to services in a distinctly rural population in Canada. In winter 2010, we conducted a baseline mail survey of 11,982 households located in rural Saskatchewan, Canada. We obtained 4620 completed household surveys. A key informant for each household responded to questions about access to medical specialists and the exact distance traveled to these services. Correlates of interest included the location of the residence within the province and within each household, socioeconomic status, household smoking status, median age of household residents, number of non-respiratory chronic conditions and number of current respiratory conditions. Analyses were conducted using log binomial regression for the outcome of interest. The overall response rate was 52%. Of households who required a visit to a medical specialist in the past 12 months, 23% reported having difficulty accessing specialist care. The magnitude of risk for encountering difficulty accessing medical specialist care services increased with the greatest distance categories. Accessing specialist care professionals by rural residents was particularly difficult for persons with current respiratory conditions.

Economic evaluation of web-based compared with in-person follow-up after total joint arthroplasty

BACKGROUND

We previously demonstrated the feasibility and clinical effectiveness of a web-based assessment following total hip or total knee arthroplasty. The purpose of the present study was to conduct an economic evaluation to compare a web-based assessment with in-person follow-up.

METHODS

Patients who had undergone total joint arthroplasty at least twelve months previously were randomized to complete a web-based follow-up or visit the clinic for the usual follow-up. We recorded travel costs and time associated with each option. We followed patients for one year after the web-based or in-person follow-up evaluation and documented any resource use related to the joint arthroplasty. We conducted cost analyses from the health-care payer (Ontario Ministry of Health and Long-Term Care) and societal perspectives. All costs are presented in 2012 Canadian dollars.

RESULTS

A total of 229 patients (118 in the web-based group, 111 in the usual-care group) completed the study. The mean cost of the assessment from the societal perspective was $98 per patient for the web-based assessment and $162 per patient for the usual method of in-person follow-up. The cost for the web-based assessment was significantly lower from the societal perspective (mean difference, $-64; 95% confidence interval [CI], $-79 to $-48; p < 0.01) and also from the health-care payer perspective (mean difference, $-27; 95% CI, $-29 to $-25; p < 0.01).

CONCLUSIONS

The web-based follow-up assessment had a lower cost per patient compared with in-person follow-up from both societal and health-care payer perspectives.

Are patients satisfied with a web-based followup after total joint arthroplasty?

BACKGROUND

A web-based followup assessment may be a feasible, cost-saving alternative of tracking patient outcomes after total joint arthroplasty. However, before implementing a web-based program, it is important to determine patient satisfaction levels with the new followup method. Satisfaction with the care received is becoming an increasingly important metric, and we do not know to what degree patients are satisfied with an approach to followup that does not involve an in-person visit with their surgeons.

QUESTIONS/PURPOSES

We determined (1) patient satisfaction and (2) patients' preferences for followup method (web-based or in-person) after total joint arthroplasty.

METHODS

We randomized patients who were at least 12 months after primary THA or TKA to complete a web-based followup or to have their appointment at the clinic. There were 410 eligible patients contacted for the study during the recruitment period. Of these, 256 agreed to participate, and a total of 229 patients completed the study (89% of those enrolled, 56% of those potentially eligible; 111 in the usual-care group, 118 in the web-based group). Their mean age was 69 years (range, 38-86 years). There was no crossover between groups. All 229 patients completed a satisfaction questionnaire at the time of their followup appointments. Patients in the web-based group also completed a satisfaction and preference questionnaire 1 year later. Only patients from the web-based group were asked to indicate preference as they had experienced the web-based and in-person followup methods. We used descriptive statistics to summarize the satisfaction questionnaires and compared results using Pearson's chi-square test.

RESULTS

Ninety-one patients (82.0%) in the usual-care group indicated that they were either extremely or very satisfied with the followup process compared with 90 patients (75.6%) who were in the web-based group (p < 0.01; odds ratio [OR] = 3.95; 95% CI, 1.79-8.76). Similarly, patients in the usual care group were more satisfied with the care they received from their surgeon, compared with patients in the web-based group (92.8% versus 73.9%; p < 0.01, OR = 1.37; 95% CI, 0.73-2.57). Forty-four percent of patients preferred the web-based method, 36% preferred the usual method, and 16% had no preference (p = 0.01).

CONCLUSIONS

Our results show moderate to high satisfaction levels with a web-based followup assessment. Patients who completed the usual method of in-person followup assessment reported greater satisfaction; however, the difference was small and may not outweigh the additional cost and time-saving benefits of the web-based followup method.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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.

Building access to specialist care through e-consultation

BACKGROUND

Limited access to specialist care remains a major barrier to health care in Canada, affecting patients and primary care providers alike, in terms of both long wait times and inequitable availability. We developed an electronic consultation system, based on a secure web-based tool, as an alternative to face-to-face consultations, and ran a pilot study to evaluate its effectiveness and acceptability to practitioners.

METHODS

In a pilot program conducted over 15 months starting in January 2010, the e-consultation system was tested with primary care providers and specialists in a large health region in Eastern Ontario, Canada. We collected utilization data from the electronic system itself (including quantitative data from satisfaction surveys) and qualitative information from focus groups and interviews with providers.

RESULTS

Of 18 primary care providers in the pilot program, 13 participated in focus groups and 9 were interviewed; in addition, 10 of the 11 specialists in the program were interviewed. Results of our evaluation showed good uptake, high levels of satisfaction, improvement in the integration of referrals and consultations, and avoidance of unnecessary specialist visits. A total of 77 e-consultation requests were processed from 1 Jan. 2010 to 1 Apr. 2011. Less than 10% of the referrals required face-to-face follow-up. The most frequently noted benefits for patients (as perceived by providers) included improved access to specialist care and reduced wait times. Primary care providers valued the ability to assist with patient assessment and management by having access to a rapid response to clinical questions, clarifying the need for diagnostic tests or treatments, and confirming the need for a formal consultation. Specialists enjoyed the improved interaction with primary care providers, as well as having some control in the decision on which patients should be referred.

INTERPRETATION

This low-cost referral system has potential for broader implementation, once payment models for physicians are adapted to cover e-consultation.

Approaches to economic evaluation in telemedicine

External validity or generalizability is a major challenge in the economic evaluation of telemedicine. There are two possible ways of increasing generalizability: the first is to use a pragmatic trial design so it better reflects normal patient caseload and everyday practice. The second is to use existing data from the literature and decision modelling to estimate the expected costs and outcomes of different alternatives. The first will increase generalizability to other patients than those in the trial and the second will increase generalizability from place to place. The objective and role of the evaluation will decide the most appropriate evaluation approach. Pragmatic trials should be used in studies where the objective is to provide measurements of costs and outcomes for a specific group of patients in a particular setting. This approach is highly relevant in telemedicine evaluations where the objective is to support local investments strategies and reimbursement systems. Decision modelling provides an overall structure for a decision problem and a formal analysis of the implications of different decisions. Modelling can simulate a trial or mimic a current system or a system that decision makers would like to use. Modelling is a useful approach when decisions need to be made about whether to invest in telemedicine within a broader context.

Skype: a tool for functional assessment in orthopaedic research

Skype is a free program which enables PC users to make video calls to other users with Internet access. We carried out a prospective review of all acromioclavicular joint hook plates for lateral-third clavicle fractures over a five-year period. Functional assessment with Oxford and Constant shoulder scores were carried out using Skype and compared to outpatient review using the Bland-Altman method. Of 36 patients (mean age 36 years), 33 had a computer with a video camera, all 33 had Internet access and 22 were already users of Skype. In total 29 patients were happy to take part in Skype assessment (83%). In comparison with outpatient review, there was a mean difference in the Oxford score of −0.48 (95% confidence interval −0.84, −0.12); the mean difference for the Constant score was −0.68 (95% confidence interval −1.08, −0.29). These differences were not clinically significant, confirming that Skype can be used as an alternative to goniometry in this clinical setting. A survey showed that 93% of 29 patients surveyed preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. The study demonstrates the potential for this new technique in providing patients with more options for follow-up.

Factors Affecting IT-Based Knowledge Management Strategy in UK Healthcare System

The technological development by the beginning of the 21st century is making it humanly impossible for unaided healthcare professionals to possess all the knowledge needed to deliver medical care with the efficacy and safety made possible by current scientific knowledge. Several healthcare organizations are adopting rigorous methods and technologies for KM as a potential solution to the knowledge predicament. However, awareness and understanding of such methods are not widespread with critics claiming that these technologies are not designed to be compatible with others neither are they interoperable.

This paper describes an effort by the NHS for individuals, organizations and partners (commercial companies supplying services to the NHS) to demonstrate their belief in the importance of improving KM in medicine and show that this can be best achieved through collaboration and consensus. It looks at National Knowledge Service, set up to provide a range of services, through one or more open-access web sites.

There is an asymmetry in most of the discussion of the field. KM, in this paper, is primarily discussed from the point of view of the user of medical knowledge. The motivation is seen to be the enhancement capabilities, and the utilization of knowledge to increase healthcare effectiveness.

Systematic review of studies of the cost-effectiveness of telemedicine and telecare. Changes in the economic evidence over twenty years

A systematic review of studies of the cost-effectiveness of telemedicine and telecare was undertaken from 1990 until September 2010. Twelve databases were searched, using economic evaluation terms combined with telemedicine terms. The search identified 80 studies which were classed as full economic evaluations; the majority (38) were cost-consequence analyses. There were 15 cost-effectiveness analyses (CEA) and seven cost-utility analyses (CUA). In the period January 2004 to September 2010 there were 47 studies. Eleven were CEA and seven were CUA. Economic tools are being increasingly used for telemedicine and telecare studies, although better reporting of the methodologies and findings of the economic evaluations is required. Nonetheless, the results of the review were consistent with previous findings, i.e. there is no further conclusive evidence that telemedicine and telecare interventions are cost-effective compared to conventional health care.

Sleep telemedicine: patient satisfaction and treatment adherence

OBJECTIVE

Obstructive sleep apnea is common, but access to diagnosis remains limited. Telemedicine may allow greater access to care; however, its effect on patient satisfaction and treatment adherence is unknown. This study compares patient satisfaction and continuous positive airway pressure (CPAP) adherence of patients seen by videoconference with those seen in person.

MATERIALS AND METHODS

New patients seen via video or in person at a sleep center completed a survey, with three questions pertaining to satisfaction with the provider. Questions were scored 1-5; the sum was the patient satisfaction score. CPAP adherence was retrospectively analyzed in patients who met the physician via video or in person. Percentage of nights CPAP was used for ≥4 h and average minutes of CPAP use per night over 2 consecutive weeks were compared.

RESULTS

A Mann-Whitney test compared patient satisfaction of the 90 subjects (of whom, 56 met physician in person and 34 via video). Mean scores (in person, 14.82; video, 14.91; p=0.851) did not differ between groups. Mann-Whitney tests compared CPAP adherence in the 172 subjects (of whom, 111 met physician in person and 61 via video). Mean percentage of nights CPAP was used ≥4 h (in person, 71%; video, 65%; p=0.198) and the average minutes per night of CPAP use (in person, 340.55; video, 305.31; p=0.153) did not differ between groups.

CONCLUSIONS

The findings indicate that patients were equally satisfied with their provider and adherent to CPAP treatment whether they were seen in person or via video. Videoconferencing may improve access to patient care without reducing patient satisfaction or treatment adherence.

A systematic review of economic analyses of telehealth services using real time video communication

Background

Telehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery - synchronous or real time video communication - rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area.

Methods

A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded.

Results

36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study.

Conclusion

Delivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.

Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness

Background

Nowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas.

Methods

General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires.

Results

There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account.

Conclusions

Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services.

Can economic evaluation in telemedicine be trusted? A systematic review of the literature

BACKGROUND

Telemedicine has been advocated as an effective means to provide health care services over a distance. Systematic information on costs and consequences has been called for to support decision-making in this field. This paper provides a review of the quality, validity and generalisability of economic evaluations in telemedicine.

METHODS

A systematic literature search in all relevant databases was conducted and forms the basis for addressing these issues. Only articles published in peer-reviewed journals and written in English in the period from 1990 to 2007 were analysed. The literature search identified 33 economic evaluations where both costs (resource use) and outcomes (non-resource consequences) were measured.

RESULTS

This review shows that economic evaluations in telemedicine are highly diverse in terms of both the study context and the methods applied. The articles covered several medical specialities ranging from cardiology and dermatology to psychiatry. The studies analysed telemedicine in home care, and in primary and secondary care settings using a variety of different technologies including videoconferencing, still-images and monitoring (store-and-forward telemedicine). Most studies used multiple outcome measures and analysed the effects using disaggregated cost-consequence frameworks. Objectives, study design, and choice of comparators were mostly well reported. The majority of the studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis.

CONCLUSION

As this paper demonstrates, the majority of the economic evaluations reviewed were not in accordance with standard evaluation techniques. Further research is needed to explore the reasons for this and to address how economic evaluation in telemedicine best can take advantage of local constraints and at the same time produce valid and generalisable results.