Using telemedicine to improve access, cost and quality of secondary care for people in prison in England: a hybrid type 2 implementation effectiveness study

Intramural Health Care Through Video Consultations and the Need for Referrals and Hospital Admissions: Retrospective Quantitative Subanalysis of an Evaluation Study

BACKGROUND

In comparison to the general population, prison inmates are at a higher risk for drug abuse and psychiatric, as well as infectious, diseases. Although intramural health care has to be equivalent to extramural services, prison inmates have less access to primary and secondary care. Furthermore, not every prison is constantly staffed with a physician. Since transportation to the nearest extramural medical facility is often resource-intensive, video consultations may offer cost-effective health care for prison inmates.

OBJECTIVE

This study aims to quantify the need for referrals to secondary care services and hospital admissions when video consultations with family physicians and psychiatrists are offered in prison.

METHODS

In 5 German prisons, a mixed methods evaluation study was conducted to assess feasibility, acceptance, and reasons for conducting video consultations with family physicians and psychiatrists. This analysis uses quantitative data from these consultations (June 2018 to February 2019) in addition to data from a sixth prison added in January 2019 focusing on referral and admission rates, as well as reasons for encounters.

RESULTS

At the initiation of the project, 2499 prisoners were detained in the 6 prisons. A total of 435 video consultations were conducted by 12 physicians (3 female and 7 male family physicians, and 2 male psychiatrists during the study period). The majority were scheduled consultations (341/435, 78%). In 68% (n=294) of all encounters, the patient was asked to consult a physician again if symptoms persisted or got worse. In 26% (n=115), a follow-up appointment with either the video consultant or prison physician was scheduled. A referral to other specialties, most often psychiatry, was necessary in 4% (n=17) of the cases. Only in 2% (n=8) of the consultations, a hospital admission was needed. Usually, hospital admissions were the result of unscheduled consultations, and the videoconferencing system was the method of communication in 88% (n=7) of these cases, while 12% (n=1) were carried out over the phone. Reasons for admissions were severe abdominal pain, hypotension, unstable angina or suspected myocardial infarction, or a suspected schizophrenic episode.

CONCLUSIONS

Most scheduled and unscheduled consultations did not require subsequent patient transport to external health care providers. Using telemedicine services allowed a prompt patient-physician encounter with the possibility to refer patients to other specialties or to admit them to a hospital if necessary.

Assessment of Stakeholder Perceptions and Cost of Implementing a Telemedicine Specialty Program at Correctional Facilities in North Carolina

Background Delivering in-person health care to the more than 1.2 million incarcerated adults can be expensive, logistically challenging, fragmented, and pose security risks. The purpose of this study was to evaluate the implementation of a specialty care telemedicine program in statewide prisons in North Carolina during the COVID-19 pandemic. Methods We evaluated the first 6 months of implementation of a new telemedicine program to deliver specialty care to adults incarcerated in 55 North Carolina prison facilities. We measured patient and practitioner perceptions and the impact on the cost of care. Results A total of 3232 telemedicine visits were completed across 55 prisons within the first 6 months of the program. Most patients reported that the ability to use telemedicine contributed to their overall personal well-being and safety. Many practitioners found that working with the on-site nursing staff to conduct physical exams and to make collective decisions were key drivers to the success of telemedicine. A direct relationship was found between the telemedicine experience and patients' preference for future visits such that as satisfaction increased, the desire to use telemedicine increased. Telemedicine reduced total costs of care by $416,020 (net: -$95,480) within the first 6 months, and $1,195,377 estimated in the first 12 months postimplementation (95% confidence interval: $1,100,166-$1,290,587). Conclusions Implementing specialty care telemedicine in prison facilities enhanced patient and practitioner experiences and reduced costs within the prison system. The implementation of telemedicine in prison systems can increase access to care and reduce public safety risks by eliminating unnecessary off-site medical center visits.

Awareness and attitudes of elderly Southeast Asian adults towards telehealth during the COVID-19 pandemic: a qualitative study

Introduction

We aimed to understand the awareness and attitudes of elderly Southeast Asians towards telehealth services during the coronavirus disease 2019 (COVID-19) pandemic in this study.

Methods

In this qualitative study, 78 individuals from Singapore (51.3% female, mean age 73.0 ± 7.6 years) were interviewed via telephone between 13 May 2020 and 9 June 2020 during Singapore's first COVID-19 'circuit breaker'. Participants were asked to describe their understanding of telehealth, their experience of and willingness to utilise these services, and the barriers and facilitators underlying their decision. Transcripts were analysed using thematic analysis, guided by the United Theory of Acceptance Use of Technology framework.

Results

Of the 78 participants, 24 (30.8%) were able to describe the range of telehealth services available and 15 (19.2%) had previously utilised these services. Conversely, 14 (17.9%) participants thought that telehealth comprised solely home medication delivery and 50 (51.3%) participants did not know about telehealth. Despite the advantages offered by telehealth services, participants preferred in-person consultations due to a perceived lack of human interaction and accuracy of diagnoses, poor digital literacy and a lack of access to telehealth-capable devices.

Conclusion

Our results showed poor overall awareness of the range of telehealth services available among elderly Asian individuals, with many harbouring erroneous views regarding their use. These data suggest that public health education campaigns are needed to improve awareness of and correct negative perceptions towards telehealth services in elderly Asians.

Facilitating dental disease screening program in prisoners using an intraoral camera in teledentistry

OBJECTIVES

To facilitate dental disease screening program in prisoners by testing the diagnostic accuracy of teledentistry examination in comparison to direct oral examination by a dentist.

MATERIALS AND METHODS

This crossover study comprised three phases. Phase I, prisoner health volunteers (PHVs) enrolled teledentistry training for an intraoral camera (IOC) use. Phase II, the PHV used IOC for examining dental diseases of prisoners who reported dental-related problems, and captured symptomatic areas. The PHV and dentist independently determined tentative dental treatment need, comprising dental fillings, scaling, extraction, and surgical removal of impacted tooth. Phase III, another dentist performed direct oral examination of the prisoners who reported problems in phase II and determined dental treatment needs. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated, using direct oral examination by dentist as a true positive.

RESULTS

Diagnostic accuracy was determined in 152 prisoners with 215 teeth. Sensitivity, specificity, PPV, and NPV of teledentistry and direct examination between two dentists were above 80%. The lowest sensitivity and specificity of teledentistry examination by the PHV were scaling and surgical removal.

CONCLUSIONS

IOC use in teledentistry facilitates dentists in dental diseases screening for prisoners with acceptable diagnostic accuracy in identifying possible treatment needs. However, the imaging obtained from teledentistry is not adequate to accurately identify all dental treatment needs.

Comparison between a fitness tracker (EquimetreTM) and standard base-apex electrocardiography in dromedary camels

Background

Personalized healthcare technology has grown explosively through the use of portable and smart monitoring devices for diagnosis. The objective of this study was to determine the practicality and usability of the EquimetreTM fitness tracker on camels in comparison to the standard base-apex system in normal and clinical cases.

Methods

Five apparently healthy adult camels, five clinical adult cases and two clinical calves were enrolled in this study. The camels were equipped with two monitoring systems: EquimetreTM and a standard base-apex electrocardiogarphy. Each tracing was evaluated for the normal ECG variable's measure, including heart rate beats per min, P-R, QRS, R-R, Q-T, S-T intervals, and P-R and S-T segments in seconds. The amplitudes for P, Q, R, S, and T-peaks were evaluated in millivolts.

Results

EquimetreTM showed stability on ECG tracing with less movement artifacts compared with the standard base-apex system. Different polarities were observed for the P-waves and T-waves between the standard base-apex system and EquimetreTM. Both devices showed perfect agreement for heart rate (ICC = 1.00, P ≥ 0.0001, 95% = 1.00-1.00) in healthy and clinical adults. A good correlation was observed for the R-R interval between the devices in healthy and clinical adults. A moderate correlation was observed between the devices for Q-peak in clinical adults, with no correlation in clinical calves.

Conclusions

This study demonstrated acceptable ECG measurements between the standard base-apex and EquimetreTM device. This suggests that EquimetreTM could be a useful device in camels for initial electrocardiographic examinations in remote areas such as deserts.

"That makes me feel human": a qualitative evaluation of the acceptability of an HIV differentiated care intervention for formerly incarcerated people re-entering community settings in South Africa

Background

Correctional settings in South Africa have disproportionately high rates of HIV infection; a large number of inmates living with HIV return to the community each year. The transition community adherence club (TCAC) intervention was a differentiated care delivery approach with structural and peer components designed to increase antiretroviral therapy (ART) adherence and HIV care engagement following release from incarceration. The objective of this study was to assess the acceptability of the TCAC intervention among HIV-infected community re-entrants to inform program revisions and future intervention designs.

Methods

This was a qualitative study set within a randomized controlled trial (RCT) of the TCAC intervention in South Africa. We conducted semi-structured, in-depth interviews with 16 re-entrants living with HIV and assigned to the intervention arm. All interviews were audio-recorded, transcribed, translated, and de-identified. Transcripts were coded and analyzed using content analysis, and acceptability was assessed using the Theoretical Framework of Acceptability (TFA).

Results

Overall, study participants reported that the TCAC intervention was acceptable. Development of supportive relationships between participants, non-judgmental attitudes from peer-facilitators, and perceived effectiveness of the intervention to support ART adherence and HIV care were noted as the most valued components. An altruistic desire to help other participants facing similar post-incarceration and HIV-related challenges was a key motivator for TCAC attendance. A lack of access to reliable transportation to intervention sites and clinic-based medication collection were described as burdens to program participation. Illicit drug use by other group members and negative social influences were also identified as potential barriers to optimal program engagement.

Conclusion

The TCAC was a well-accepted model of differentiated care delivery among re-entrants living with HIV in South Africa. To further enhance intervention acceptability for future scale-ups, program revisions should address logistical barriers related to reaching TCAC sites and implementing ART distribution at TCAC group sessions.

Integration, population commissioning and prison health and well-being – an exploration of benefits and challenges through the study of telemedicine

Purpose

This paper seeks to understand relationships between prison healthcare and integrated care systems (ICS), including how these affect the delivery of new healthcare interventions. It also aims to understand how closer integration between prison and ICS could improve cross system working between community and prison healthcare teams, and highlights challenges that exist to integration between prison healthcare and ICS.

Design/methodology/approach

The study uses evidence from research on the implementation of a pilot study to establish telemedicine secondary care appointments between prisons and an acute trust in one English region (a cross-system intervention). Qualitative interview data were collected from prison (n = 12) and community (n = 8) healthcare staff related to the experience of implementing a cross-system telemedicine initiative. Thematic analysis was undertaken on interview data, guided by an implementation theory and framework.

Findings

The research found four main themes related to the closer integration between prison healthcare and ICS: (1) Recognition of prison health as a priority; (2) Finding a way to reconcile networks and finances between community and prison commissioning; (3) Awareness of prison service influence on NHS healthcare planning and delivery; and (4) Shared investment in prison health can lead to benefits.

Originality/value

This is the first article to provide research evidence to support or challenge the integration of specialist health and justice (H&J) commissioning into local population health.

Ambulatory Virtual Care During a Pandemic: Patient Safety Considerations

BACKGROUND

The COVID-19 pandemic prompted sudden and fundamental changes in health care, including a rapid rise in the utilization of telehealth services in the ambulatory setting. With the unprecedented and significant decline in traditional office-based visits and procedures, novel patient safety risks and challenges emerged.

METHODS

The ambulatory practices at our quaternary care, academic medical center experienced a 200-fold increase in virtual visit volume between February and April 2020. We convened a multidisciplinary working group dedicated to evaluating quality and safety when providing virtual visits during a pandemic. Our primary outcome was patient experience with virtual care delivery, which was assessed by leveraging patient complaint data and patient satisfaction survey data.

RESULTS

For our main focus of patient experience and satisfaction, survey data were analyzed from the approximately 76,616 virtual visit encounters that occurred between March 1, 2020, and April 21, 2020. During this period, 5 patient complaints were filed to the Patient Advocacy Department. Overall, patient satisfaction with telehealth remained stable and high at >93% from February to May 2020. As we assessed these data each month, our working group developed risk mitigation strategies in response to the novel challenges presented by the use of telemedicine due to the COVID-19 pandemic while working to maintain patient satisfaction with care. We identified quality and safety issues around patient factors including optimal triage of patients and use of technology. We also evaluated accessibility to virtual platforms and logistics such as coordination of care for diagnostic testing. Finally, a guidance document was created and communicated to our diverse ambulatory practices to support clinicians.

CONCLUSIONS

Ambulatory virtual care delivery requires a dynamic, flexible model of care through continuous rapid-cycle process improvement to mitigate patient safety risks during a pandemic, incorporating both provider and patient perspectives.

Implementation of a hepatology and gastroenterology teleconsultation for our penitentiary center

The use of telemedicine in Penitentiary Centers (PC) is an effective measure to improve quality access to specialized care (secondary prevention) and reduces the inherent costs derived from physical consultations of inmates in hospitals.