Use of specialty OB consults during high-risk pregnancies in a Medicaid-covered population: initial impact of the Arkansas ANGELS intervention

The use and role of telemedicine in maternal fetal medicine around the world: an up-to-date

Purpose

The aim of this narrative review is to sumarize data about the use and role of telemedicine in maternal fetal medicine (MFM).

Methods

We searched pubmed and scopus to find articles about telemedicine in MFM by using the terms telmedicine or telehealth and maternal fetal medicine.

Results

Telehealth has been widely used for several medical specialties. During the coronavirus disease 2019 (COVID-19) pandemic, telehealth has gained investment and further research. Even though telemedicine in MFM has not been frequently applied, from 2020 onwards it has increased in both implementation and acceptance worldwide. The need to screen the patients in overloaded centers in a pandemic scenario required telemedicine in MFM, which has exhibited consistently good results concerning health and budget. The aim of this study was to review the telehealth programs and research focused on MFM around the world. Few studies have been applied to MFM and even fewer in developing and undeveloped countries. The majority of studies were concentrated in the USA and in Europe.

Conclusion

Further research is needed, especially in non-developed countries, to comprehend the potential role of telemedicine in MFM for improving the life quality of the patients, health professionals, and to be cost-efficient.

A Review of Prenatal Care Delivery to Inform the Michigan Plan for Appropriate Tailored Health Care in Pregnancy Panel

OBJECTIVE

To perform a literature review of key aspects of prenatal care delivery to inform new guidelines.

DATA SOURCES

A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction.

TABULATION, INTEGRATION, AND RESULTS

Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth.

CONCLUSION

Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

Telemedicine in High-Risk Obstetrics

Telemedicine involves the use of technology to provide services to patients and share medical information. Telemedicine's use has increased as technology has advanced. It allows for medicine to be practiced from a distance to reach patients in rural or underserved areas. Telemedicine has widespread uses in high-risk obstetrics, including management of diabetes, diagnosis and management of hypertensive disorders of pregnancy, screening for fetal malformations with teleultrasound, delivering care to underserved areas, and more. The use of telemedicine to provide care to patients and information to health care providers at a distance has been well accepted by the patients and providers.

Risk Stratification of Fetal Cardiac Anomalies in an Underserved Population Using Telecardiology

OBJECTIVE

To evaluate a fetal telecardiology program in a medically underserved area.

METHODS

We conducted a prospective case series of pregnant women at 18-38 weeks of gestation with risk factors for fetal congenital heart disease. Obstetric ultrasonographers performed fetal echocardiograms (local site) that were read in real time. The results were given to the mother by a fetal cardiologist at a children's hospital 243 miles and two mountain passes away (distant site). We evaluated the fetal telecardiology program in five domains: 1) education of obstetric ultrasonographers before initiation of telecardiology services, 2) process and efficiency, 3) patient satisfaction, 4) economic effects, and 5) accuracy of cardiac diagnosis and success of risk stratification.

RESULTS

The program was initiated on November 12, 2015, and here we describe its first 37 months. Over the initial training period of 3 months and about 70 examinations, obstetric ultrasonographers improved their identification of fetal congenital heart disease. Telecardiology was performed once a week and also for suspected fetal congenital heart disease or arrhythmia outside clinic hours, for a total of 455 examinations. All mothers preferred having their fetal cardiac evaluations performed locally as opposed to traveling to the distant center. The estimated cost to parents for fetal cardiac evaluation at the distant center was nine times greater than that of telecardiology ($581 vs $61). Congenital heart disease or arrhythmia was diagnosed in 28 and 15 fetuses, respectively; there was one false-negative result. All fetuses were correctly risk-stratified with respect to delivery location.

CONCLUSIONS

Neither diagnostic quality nor patient satisfaction were sacrificed with telecardiology. The program was feasible, empowered the local health care providers and ultrasonographers, offered strong economic advantages to families, and offered the benefit of timely standard-of-care, face-to-face consultation without travel. Based on the success of this program, further studies are warranted to assess its replicability.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Validation of Newly Developed Surveys to Evaluate Patients' and Providers' Satisfaction with Telehealth Obstetric Services

Background: Patient and/or provider satisfaction and experience are among the most important indicators for quality assurance of health care services, including telehealth. Validated surveys should be used for this purpose to provide reliable information for a program evaluation. Objective: To validate the newly developed satisfaction surveys, report patient, and provider satisfaction with Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) telehealth services. Methods: Two self-administered paper surveys were developed by a multidisciplinary team. The surveys were validated among obstetric patients who received telehealth services in 2016 and providers in Arkansas from July to August 2017. Psychometric testing was performed to establish reliability and validity of both the surveys. Descriptive statistics was performed to describe patient and provider satisfaction. Results: A total of 89 patient- and 66 provider surveys were analyzed. Construct validity and internal consistency reliability (Cronbach's α >0.7) were confirmed on both the surveys. The majority of patients were highly satisfied with telehealth services and reported positive perceptions toward future use of services. In the past 12 months, telehealth (78.6%) was the most used ANGELS service by providers. Finally, >90% of the providers reported high satisfaction and rated telehealth services as "excellent." Conclusions: The newly developed patient and provider telehealth surveys were reliable and valid. The surveys also demonstrated that the telehealth services were well-accepted and highly valued in a sample of obstetric patients and providers. As both surveys are short, they can be used in routine evaluation of patient and provider satisfaction with similar telehealth programs in the country.

Telemedicine: a Primer

PURPOSE OF REVIEW

Due to rapid advancements in quality of real-time, interactive, audio-visual, and digital technologies as well as impressive gains in internet speed and capacity, medicine delivered over distance is happening faster than many healthcare providers and leaders can grasp.

RECENT FINDINGS

Depending on which market report you ascribe to, industry projections for the global compounded annual growth rate of telemedicine are between 13 and 27%, with valuation growing to over 20 billion US dollars in the next several years. The Mayo Clinic has reworked its entire telemedicine interest to a model with centralized operations, one virtual technology platform, standardized training, and connectedness for all of its locations. The National Quality Forum spent 2016 and 2017 formulating 70 some pages of recommendations for expanded measures to valuate telemedicine over the foreseeable future. There are so many patient experience studies indicating high satisfaction with telemedicine, that professionals in the industry accept it as fact. Telemedicine is leaving novel to the past. This short, informative piece of writing includes expert opinion and research findings about what is telemedicine, why one should practice telemedicine, and how one should approach implementation; a primer from which to grow.

Telemedicine: a Primer

PURPOSE OF REVIEW

Due to rapid advancements in quality of real-time, interactive, audio-visual, and digital technologies as well as impressive gains in internet speed and capacity, medicine delivered over distance is happening faster than many healthcare providers and leaders can grasp.

RECENT FINDINGS

Depending on which market report you ascribe to, industry projections for the global compounded annual growth rate of telemedicine are between 13 and 27%, with valuation growing to over 20 billion US dollars in the next several years. The Mayo Clinic has reworked its entire telemedicine interest to a model with centralized operations, one virtual technology platform, standardized training, and connectedness for all of its locations. The National Quality Forum spent 2016 and 2017 formulating 70 some pages of recommendations for expanded measures to valuate telemedicine over the foreseeable future. There are so many patient experience studies indicating high satisfaction with telemedicine, that professionals in the industry accept it as fact. Telemedicine is leaving novel to the past. This short, informative piece of writing includes expert opinion and research findings about what is telemedicine, why one should practice telemedicine, and how one should approach implementation; a primer from which to grow.

US and territory telemedicine policies: identifying gaps in perinatal care

BACKGROUND

Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories).

OBJECTIVE

We sought to summarize the telemedicine policies of states and territories and assess if maternal and neonatal risk-appropriate care is specified.

STUDY DESIGN

We conducted a 2014 systematic World Wide Web-based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis.

RESULTS

Overall, 36 jurisdictions (32 states; 3 territories; and District of Columbia) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. In all, 26 jurisdictions (22 states; 3 territories; and District of Columbia) (44%), referenced all topics. Only 3 jurisdictions (3 states; 0 territories) (5%), had policy language specifically addressing perinatal care.

CONCLUSION

The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource-challenged jurisdictions.

Location of childbirth for rural women: implications for maternal levels of care

BACKGROUND

A recent American Congress of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (MFM) consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care.

OBJECTIVE

We sought to characterize rural women who give birth in nonlocal hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with nonlocal childbirth.

STUDY DESIGN

This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in 9 states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a nonlocal hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require MFM consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation).

RESULTS

The rate of nonlocal childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (adjusted odds ratio [AOR], 0.76; 95% confidence interval [CI], 0.68-0.86 for Medicaid vs private insurance) and by clinical conditions including multiple gestation (AOR, 1.82; 95% CI, 1.58-2.1), preterm deliveries (AOR, 2.41; 95% CI, 2.17-2.67), and conditions that may require MFM services or consultation (AOR, 1.28; 95% CI, 1.22-1.35). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a nonlocal hospital (AOR, 1.94; 95% CI, 1.64-2.31).

CONCLUSION

Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in nonlocal hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.

Distributing medical expertise: the evolution and impact of telemedicine in arkansas

Arkansas's telemedicine system has evolved since 2003 from a support mechanism for high-risk pregnancy consultations to an initiative that spans medical specialties, including asthma care, pediatric cardiology, gynecology, and mental health. The system has also expanded care to diverse populations, including incarcerated women and people with HIV/AIDS. This article describes the system's evolution, organization, and diverse activities. It also shows how telemedicine can have a positive impact on a rural state and how such a state can become an engine for change regionally. The Arkansas telemedicine system faced classic challenges to uptake and function, in building and sustaining funding, in obtaining insurance reimbursement for services, and in educating patients and providers. The system's impacts on health outcomes and medical practice culture have also reached beyond patient care and provider support. The existing yet continually evolving telemedicine infrastructure and partnerships in Arkansas will respond to the state's inevitable health care reform adaptations from the Affordable Care Act and could provide direction for other states seeking to adopt or expand their telemedicine efforts.