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

Adoption of telemedicine for obesity treatment during the COVID-19 pandemic achieved comparable outcomes to in-person visits

Background

During the COVID-19 pandemic, weight loss programs rapidly transitioned to a virtual model, replacing in-person clinic visits. We sought to compare the observed weight loss and adherence to treatment between patients referred for intensive behavioral therapy (IBT) who were treated via telemedicine and those treated in person.

Methods

After IRB approval, we conducted a retrospective observational study of patients referred for clinical bariatric IBT between January 2019 and June 2021 who were followed in person or via telemedicine. The primary endpoint was the percentage of excess BMI loss (EBL%); secondary endpoints included treatment adherence, duration of follow-up, and number of completed visits.

Results

During the study period, 139 patients were seen for at least one IBT session for weight management: 62 were followed up in person (IP) and 77 via telemedicine (TM). The mean age, baseline BMI, and follow-up duration between the groups were similar. In the IP and TM groups, the EBL% was -24.7 ± 24.7 and -22.7 ± 19.5 (P = 0.989) and loss to follow-up after the first visit was 27.4% and 19.5% (P = 0.269), respectively.

Conclusion

For the management of obesity, weight loss programs delivered via telemedicine can achieve similar outcomes to those provided via classical in-person visits. This study suggests that the integration of telecare into clinical practice in bariatric medicine should be considered in the future. Emerging technologies may allow adequate patient follow-up in multiple scenarios, specifically non-critical chronic disorders, and bring unanticipated benefits for patients and healthcare providers.

Digital Health as a Mechanism to Reduce Neonatal Intensive Care Unit Admissions: Retrospective Cohort Study

Background

Admission to the neonatal intensive care unit (NICU) is costly and has been associated with financial and emotional stress among families. Digital health may be well equipped to impact modifiable health factors that contribute to NICU admission rates.

Objective

The aim of the study is to investigate how the use of a comprehensive prenatal digital health platform is associated with gestational age at birth and mechanisms to reduce the risk of admission to the NICU.

Methods

Data were extracted from 3326 users who enrolled in a comprehensive digital health platform between January 2020 and May 2022. Multivariable linear and logistic regression models were used to estimate the associations between hours of digital health use and (1) gestational age at birth and (2) mechanisms to reduce the risk of a NICU admission. Multivariable logistic regression models estimated the associations between (1) gestational age at birth and (2) mechanisms to reduce the risk of a NICU admission and the likelihood of a NICU admission. All analyses were stratified by the presence of any gestational conditions during pregnancy.

Results

For users both with and without gestational conditions, hours of digital health use were positively associated with gestational age at birth (in weeks; with gestational conditions: β=.01; 95% CI 0.0006-0.02; P=.04 and without gestational conditions: β=.01; 95% CI 0.0006-0.02; P=.04) and mechanisms that have the potential to reduce risk of a NICU admission, including learning medically accurate information (with gestational conditions: adjusted odds ratio [AOR] 1.05, 95% CI 1.03-1.07; P<.001 and without gestational conditions: AOR 1.04, 95% CI 1.02-1.06; P<.001), mental health management (with gestational conditions: AOR 1.06, 95% CI 1.04-1.08; P<.001 and without gestational conditions: AOR 1.03, 95% CI 1.02-1.05; P<.001), and understanding warning signs during pregnancy (with gestational conditions: AOR 1.08, 95% CI 1.06-1.11; P<.001 and without gestational conditions: AOR 1.09, 95% CI 1.07-1.11; P<.001). For users with and without gestational conditions, an increase in gestational age at birth was associated with a decreased likelihood of NICU admission (with gestational conditions: AOR 0.62, 95% CI 0.55-0.69; P<.001 and without gestational conditions: AOR 0.59, 95% CI 0.53-0.65; P<.001). Among users who developed gestational conditions, those who reported that the platform helped them understand warning signs during pregnancy had lower odds of a NICU admission (AOR 0.63, 95% CI 0.45-0.89; P=.01).

Conclusions

Digital health use may aid in extending gestational age at birth and reduce the risk of NICU admission.

Virtual Motivational Interviewing (VIMINT) to support physical activity: Experiences of older adults and counsellors

The aim of this study was to explore the experiences of older adults and counsellors involved in virtual motivational interviewing (MI). This study was part of the Virtual Motivational INTerviewing (VIMINT) feasibility trial of virtual MI for physical activity in older adults. A descriptive qualitative design utilized content analysis. Seven older adults and three counsellors were interviewed. Four categories were developed: (i) Benefits and limitations of using technology (ii) Relationships between older adults and counsellors (iii) MI skills and spirit and (iv) Effects of virtual MI. Older adults and counsellors reported that receiving/delivering MI virtually was convenient and flexible. They described reduced non-verbal communication in virtual MI. Virtual MI facilitates interpersonal relationships, and counsellors reported that MI skills and spirit can be applied virtually. This study showed that virtual MI offers potential benefits with some limitations. The findings could inform future research involving virtual delivery of MI.

Cloud Horizons: Strengthening Rural Healthcare Through Telemedicine's Digital Canopy

Introduction

Cloud-based telemedicine holds promise for improving healthcare accessibility and delivery, particularly in rural areas of developing countries like Tanzania. However, little is known about its determinants and benefits in such contexts. This study investigates the factors influencing the usage of telemedicine in Mvomero district, Morogoro region, Tanzania, focusing on both supply and demand sides.

Method

Using structured interviews and key informant interviews, the study examines various cloud-based telemedicine platforms, including remote monitoring, electronic health records, cloud-based storage, and machine learning algorithms. The study used descriptive statistics to analyze quantitative data, while thematic analysis was used to analyze qualitative data.

Results

Results reveal several factors influencing telemedicine usage. On the demand side, perceived benefits (53.96%), technology cost (62.79%), legal practices (62.79%), and resource availability and affordability (49.77%) are crucial. On the supply side, technological innovation (35%) and access to financial resources (43%) play pivotal roles. Environmental and institutional factors such as political willingness (38%) and regulatory support (34%) also impact telemedicine usage. Moreover, results reveal that cloud-based telemedicine platforms in rural healthcare facilities have several benefits including improved access (32.74% to 57.44%), cost efficiency (37.88% to 54.82%), timely consultations (56.83% to 65.21%), health monitoring, and prescription management (43.89% to 75.90%). Private facilities particularly emphasize health monitoring.

Conclusion

Adopting telemedicine technologies can revolutionize rural healthcare by providing customized and easily accessible services. Policymakers can use these findings to develop targeted strategies, including subsidized infrastructure, innovative financing models, and clear regulatory frameworks. Clear guidelines on data transfer and privacy are essential to ensure legal compliance and equitable access to telemedicine benefits. Simplifying registration requirements and implementing explicit consent mechanisms are recommended to address data privacy concerns. These measures aim to promote operational efficiency, data safety, and enhanced health outcomes in resource-limited settings.

A qualitative reflexive thematic analysis of innovation and regulation in hearing health care

BACKGROUND

The hearing health sector is an example of a health sector that is experiencing a period of rapid innovation driven by digital technologies. These innovations will impact the types of interventions and services available to support the communication of deaf and hard-of-hearing individuals. This study explored the perceptions of informed participants on the topic of innovation and regulation within hearing healthcare in Australia and the United Kingdom (UK).

METHODS

Participants (N = 29, Australia [n = 16], UK [n = 13]) were purposively sampled and joined one of two online workshops. Participants included adults with hearing loss and family members, hearing health professionals, academics/researchers, representatives of hearing device manufacturers, regulators and policymakers. Workshop data were analysed using reflexive thematic analysis.

RESULTS

Participants conceptualised the hearing health sector as a network of organisations and individuals with different roles, knowledge and interests, in a state of flux driven by innovation and regulation. Innovation and regulation were perceived as mechanisms to ensure quality and mitigate risk within a holistic approach to care. Innovations encompassed technological as well as non-technological innovations of potential benefit to consumers. Participants agreed it was essential for innovation and regulation to be congruent with societal values. Critical to ethical congruence was the involvement of consumers throughout both innovation and regulation stages, and the use of innovation and regulation to tackle stigma and reduce health disparities. Participants expressed the desire for accessible and inclusive innovation in the context of fair, transparent and trustworthy commercial practices.

CONCLUSIONS

This study explored how stakeholders within the hearing health sector understand and make sense of innovation and the role of regulation. Overall, and despite reservations relating to health care professionals' changing roles and responsibilities, innovation and regulation were conceptualised as beneficial when situated in the context of holistic, whole-person, models of care. The results of this study will inform considerations to support the development and implementation of innovations and regulation within the hearing sector and across other health sectors influenced by technological advances.

Digital Reimbursement Systems in a Student-Run Clinic

The increasing reliance on digital tools for standard healthcare practices in uninsured populations is poorly understood. This study aims to assess the impacts of a newly implemented digital reimbursement system at a student-run primary care clinic associated with an academic medical institution serving uninsured New York City residents. Pharmacy records of 94 unique patients receiving a total of 2770 reimbursements between October 17th, 2016, and May 18th, 2023, were analyzed. Patients were divided into two groups (in-person vs. digital) based on their reimbursement preferences type. Demographic analyses were performed in addition to assessing reimbursement volumes, number of refunds, and duration until receipt of payment for each group. The clinic's total monthly reimbursement volume, number of prescriptions, and number of patients for the period before introduction of digital refunds was compared to the period after. The mean age (in-person = 52.7 ± 14.7 years, digital = 54.9 ± 12.9 years) was not statistically different between the groups. Patients in the digital group requested on average more refunds (digital = 47 refunds, in-person = 14 refunds), received higher total reimbursement amount (digital = $1131.24, in-person = $289.36), and they were reimbursed faster (digital = 56 days, in-person = 62 days). Since the introduction of the digital reimbursement option, our three-month reimbursement volume more than doubled from $481 to $1298. The average number of monthly reimbursements increased from 27 to 45 refunds, and the number of monthly patients increased from 6 to 9 patients. In summary, digital reimbursement options can facilitate medication reimbursement among uninsured patients. These results suggest that digital reimbursement systems result in higher utilization, faster refunds, and larger total reimbursements amount for uninsured and underserved patients.

Enhancing Access Through Language-Tailored Approach in Telehealth and Veterans Video Connect: Traumatic Brain Injury (TBI) Veterans Satisfaction Assessment

INTRODUCTION

Traumatic brain injury (TBI) can impact language processing, necessitating language-tailored approaches. Telehealth may expand rural Veterans' access but has unknown feasibility for language preferences. This study explored telehealth/Veterans Video Connect satisfaction for Spanish/English TBI screening.

MATERIALS AND METHODS

The study was approved by the VA Caribbean Healthcare System Institutional Review Board and the Research and Development Committee. Mixed methods evaluated telehealth satisfaction in Veterans receiving TBI assessments from October 2021 to October 2023. Surveys included the 16-item Clinical Video Telehealth (CVT) questionnaire on communication, technical factors, coordination, and overall satisfaction, and the 21-item Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ) examining usefulness, ease of use, manners, quality, and satisfaction. Mean domain/item scores were calculated among 57 Veterans, 12 English, and 45 Spanish-speaking. Semi-structured interviews also elicited user experiences from 4 providers and 5 Veterans. Transcripts underwent qualitative coding for themes using Atlas.ti.8.

RESULTS

On CVT (0-5 scale), overall satisfaction averaged 4.50 (English) and 4.69 (Spanish). Lowest scoring item for English users was easy video connection (4.25), while unclear expectations had the lowest Spanish score (3.60). For TSUQ, overall mean scores were 4.50 (English) and 4.67 (Spanish), with improved health post-telehealth having the lowest average (English 3.33, Spanish 3.67). Qualitatively, Veterans and providers noted strengths like access and communication but weaknesses around connectivity, care delays, and privacy. Differences emerged regarding convenience (Veterans) versus operational barriers (providers). There was a strong positive correlation for Spanish surveys and a moderate correlation for English surveys (r = 0.71 Spanish surveys, r = 0.69 English surveys) between TSUQ and CVT for individual respondents.

CONCLUSIONS

Patients conveyed positive experiences, but qualitative data revealed actionable targets for optimization like infrastructure and coordination improvements. Key limitations include small samples and lack of comparison to in-person care. Still, high satisfaction coupled with specific user feedback highlights telehealth's potential while directing enhancements. The results found high Veteran satisfaction with Spanish/English TBI telehealth, but mixed methods illuminated salient domains for better accommodating user needs, particularly regarding logistics and technology. Rigorously integrating experiences with metrics over expanded diverse samples and modalities can further guide refinements to enhance telehealth with a language-tailored approach.

EHealth technologies in parental care for preterm infants: an integrative review

The eHealth technologies promote parental care practices for preterm infants. Nonetheless, we should underscore the abundant information and available apps and disparities in these resources' quality, usability, and reliability. This article examines eHealth technologies directed at parents to care for preterm infants. An integrative review was conducted across the principal health databases (Capes, EBSCO, BVS, PubMed, Scholar, and SciELO), selecting works published from 2011 to 2022 in Portuguese and English, focusing on the use of eHealth technologies for the care of preterm infants. We identified 13 articles related to information and communication technologies in strategies for educating and promoting the health of preterm infants and their parents and the importance of evaluating and validating eHealth technologies in maternal and child health promotion. Properly validated eHealth technologies can be crucial in supporting parents in promoting health and providing care for preterm infants after hospital discharge, which, in turn, can drive the evolution of healthcare systems and improve clinical practices.

Real-time video telerehabilitation shows comparable satisfaction and similar or better attendance and adherence compared with in-person physiotherapy: a systematic review

QUESTION

How does physiotherapy delivered by real-time, video-based telerehabilitation compare with in-person delivery for the outcomes of attendance, adherence and satisfaction?

DESIGN

Systematic review of randomised control trials indexed in PubMed, CINAHL, Embase, Cochrane and PEDro on 12 March 2024.

PARTICIPANTS

Adults aged > 18 years.

INTERVENTION

Physiotherapy delivered via real-time video telerehabilitation.

OUTCOME MEASURES

Attendance, adherence and satisfaction.

RESULTS

Eight studies were included for attendance (n = 1,110), nine studies for adherence (n = 1,190) and 12 studies for satisfaction (n = 1,247). Telerehabilitation resulted in attendance at treatment sessions that was 8% higher (95% CI -1 to 18) and adherence to exercise programs that was 9% higher (95% CI 2 to 16) when compared with in-person physiotherapy. Satisfaction was similar with both modes of delivery (SMD 0.03 in favour of telerehabilitation, 95% CI -0.23 to 0.28). The level of certainty assessed by GRADE ranged from very low to low, primarily due to inconsistency and high risk of bias.

DISCUSSION

Attendance at appointments among participants assigned to telerehabilitation was somewhere between similar to and considerably higher than among control participants. Adherence to self-management with telerehabilitation was better than with in-person delivery, although with some uncertainty about the magnitude of the effect. Reported satisfaction levels were similar between the two modes of treatment delivery. Given the significance of attendance, adherence and satisfaction for successful outcomes, telerehabilitation offers a valuable alternative mode for physiotherapy delivery.

CONCLUSION

Real-time telerehabilitation has potentially favourable effects on attendance at treatment appointments and adherence to exercise programs, with similar satisfaction when compared with traditional in-person physiotherapy.

REGISTRATION

PROSPERO CRD42022329906.

Economic impact of outpatient follow-up using telemedicine vs in-person visits for patients in general surgery: A secondary analysis of a randomized clinical trial

INTRODUCTION

Innovation in internet connectivity and the Covid 19 pandemic have caused a dramatic change in the management of patients in the medical field, boosting the use of telemedicine. A comparison of clinical outcomes and satisfaction between conventional face-to-face and telemedicine follow-up in general surgery, an economic evaluation is mandatory. The aim of the present study was to compare the differences in economic costs between these two outpatient approaches in a designed randomized controlled trial (RCT).

METHODS

A RCT was conducted enrolling 200 patients to compare conventional in-person vs. digital health follow-up using telemedicine in the outpatient clinics in patients of General Surgery Department after their planned discharge. After a demonstration that no differences were found in clinical outcomes and patient satisfaction, we analyzed the medical costs, including staff wages, initial investment, patent's transportation and impact on social costs.

RESULTS

After an initial investment of 7527.53€, the costs for the Medical institution of in-person conventional follow-up were higher (8180.4€) than those using telemedicine (4630.06€). In relation to social costs, loss of productivity was also increased in the conventional follow-up.

CONCLUSION

The use of digital Health telemedicine is a cost-effective approach compared to conventional face-to-face follow-up in patients of General Surgery after hospital discharge.

Telemedicine in Cardiology: Enhancing Access to Care and Improving Patient Outcomes

Telemedicine has gained significant recognition, particularly since the COVID-19 pandemic. However, its roots date back to its significant role during major epidemic outbreaks such as severe acute respiratory syndrome (SARS), H1N1 and H7N9 influenza, and Middle East respiratory syndrome (MERS), where alternate means of accessing healthcare were adopted to combat the outbreak while limiting the spread of the virus. In Sub-Saharan Africa, telemedicine has supported healthcare delivery, patient and professional health education, disease prevention, and surveillance, starting with its first adoption in Ethiopia in 1980. In the United States, telemedicine has significantly impacted cardiology, particularly at-home monitoring programs, which have proven highly effective for patients with abnormal heart rhythms. Devices such as Holter monitors, blood pressure monitors, and implantable cardioverter-defibrillators have reduced mortality rates and hospital readmissions while improving healthcare efficiency by saving healthcare costs. However, the COVID-19 pandemic accelerated the adoption of telemedicine, as evidenced by a dramatic increase in telemedicine visits at institutions like New York University (NYU) Langone Health during and post-COVID-19 pandemic. In addition, telemedicine has also facilitated cardiac rehabilitation and improved access to specialized cardiology care in rural and underserved areas, reducing disparities in cardiovascular health outcomes. As technology advances, telemedicine is poised to play an increasingly significant role in cardiology and healthcare at large, enhancing patient management, healthcare efficiency, and cost reduction. This review underscores the significance of telemedicine in cardiology, its challenges, and future directions.

A physical therapist and nurse practitioner model of care for chronic back pain using telehealth: Diagnostic and management concordance

INTRODUCTION

Virtual care using videoconference links between urban-based physical therapists and nurse practitioners in rural primary care may overcome access challenges and enhance care for rural and remote residents with chronic low back disorders (CBD). The purpose of this study was to evaluate the concordance of this new model of care with two traditional models.

METHODS

In this cross-sectional study design, each of 27 participants with CBD were assessed by: 1) a team of a nurse practitioner (NP) located with a patient, joined by a physical therapist (PT) using videoconferencing (NP/PTteam); 2) in-person PT (PTalone); and 3) in-person NP (NPalone). Diagnostic and management concordance between the three groups were assessed with percent agreement and kappa.

RESULTS

Overall diagnostic categorization was compared for PTalone versus NPalone and NP/PTteam: percent agreement was 77.8% (k = 0.474, p = 0.001) and 74.1% (k = 0.359, p = 0.004), respectively. In terms of management recommendations, the PTalone and NPalone demonstrated strong agreement on "need for urgent surgical referral" (92.6%, k = 0.649 (p < 0.00) and slight agreement for "refer to primary physician for pharmacology, lab or imaging" (81.5%, k = 0.372 (p = 0.013). The PTalone and NP/PTteam demonstrated strong agreement on "need for urgent surgical referral" (96.3%, k = 0.649, p = 0.000) and "recommendation for PT follow up" (88.9%, k = 0.664, p = 0.000).

DISCUSSION

The diagnostic categorization and management recommendations of the team using videoconferencing for CBD were similar to decisions made by an in-person PT. This model of care may provide a method for enhancing access to PT for CBD assessment and initial management in underserved areas.

Analysis of the costs of teleconsultation for the treatment of diabetes mellitus in the SUS

OBJECTIVE

To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation.

METHOD

Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively.

RESULTS

Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation.

CONCLUSION

The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.

Effects of a nurse-led eHealth programme on functional outcomes and quality of life of patients with stroke: a pooled analysis of randomized controlled trials

Background

Stroke remains a leading cause of disability worldwide. Nurse-led eHealth programs have emerged as a potentially effective strategy to improve functional outcomes and quality of life in stroke survivors. However, the variability of study designs and outcomes measured across trials necessitates a pooled analysis to comprehensively assess the efficacy of these interventions. This protocol outlines the methodology for a pooled analysis that aims to synthesize evidence from randomized controlled trials (RCTs) evaluating nurse-led eHealth interventions for stroke patients.

Methods and analysis

This pooled analysis will be conducted according to the PRISMA guidelines. We will include RCTs that evaluate nurse-led eHealth programs and report on functional outcomes or quality of life in stroke patients. Comprehensive searches of electronic databases including Pubmed, EMBASE, the Cochrane Library, CINAHL, and PsycINFO will be conducted with a predefined search strategy. Study selection will involve screening titles and abstracts, followed by full-text review using explicit inclusion and exclusion criteria. Data extraction will be undertaken independently by two reviewers. The risk of bias will be assessed through the Cochrane Risk of Bias tool. Additionally, the quality of evidence for each outcome will be evaluated using the GRADE approach. Meta-analyses will be performed using random-effects models, and heterogeneity will be quantified using the I2 statistic. Subgroup and sensitivity analyses will explore potential sources of heterogeneity.

Discussion and conclusions

This pooled analysis is poised to provide a nuanced understanding of the effectiveness of nurse-led eHealth programs in stroke rehabilitation, leveraging a thorough methodological framework and GRADE tool to ensure robustness and reliability of evidence. The investigation anticipates diverse improvements in patient outcomes, underscoring the potential of personalized, accessible eHealth interventions to enhance patient engagement and treatment adherence. Despite the challenges posed by the heterogeneity of interventions and rapid technological advancements, the findings stand to influence clinical pathways by integrating eHealth into standard care, if substantiated by the evidence. Our study's depth and methodological rigor possess the potential to initiate changes in healthcare policy, advocating for the adoption of eHealth and subsequent investigations into its cost-efficiency. Ultimately, we aim to contribute rich, evidence-based insights into the burgeoning field of digital health, offering a foundational assessment of its applications in stroke care. Our data is expected to have a lasting impact, not only guiding immediate clinical decisions but also shaping the trajectory of future healthcare strategies in stroke recovery.

Systematic review registration

Identifier (CRD42024520100: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=520100).

A Year After Implementation of the Telehealth Waiver: Being Offered and Utilizing Video-Specific Telehealth Among Dual-Eligible Medicare Recipients During the COVID-19 Pandemic

OBJECTIVE

Telehealth is an essential tool to provide access to care while reducing infection exposure for high-risk populations during the COVID-19 pandemic. Our study aims to examine factors associated with telehealth availability and usage among Medicare and dual-eligible recipients 1 year after implementation of the Medicare's temporary telehealth waiver.

DESIGN, SETTING, AND PARTICIPANT

A cross-sectional, phone survey with a national representative sample of Medicare recipients. We obtained a final study sample from the Winter 2021 COVID-19 Supplement of Medicare Current Beneficiary Survey dataset (N = 10 586). We examined associations for being offered and having had telehealth visits or any video telehealth visits during the pandemic since November 1, 2020.

MAIN OUTCOME MEASURES

Our primary outcomes were being offered any telehealth, being offered any video telehealth, having had any telehealth visit, and having had any video telehealth.

RESULTS

Although dual eligibility was not significantly associated with being offered or having had any telehealth services during the pandemic, those who were dual eligible were more likely to have had video telehealth visits (adjusted odds ratio = 1.39, 95% confidence interval 1.04-1.86, P = .03) compared with those with non-dual eligibility. Recipients with disability eligibility, technology access, and severe chronic conditions were more likely to have been offered or have had telehealth. At the same time, those who lived in the nonmetropolitan area were less likely to have been offered or have had telehealth, including video telehealth.

CONCLUSIONS

Our findings suggest that the federal waivers to expand telehealth services were successful in continuing care for vulnerable Medicare recipients. The providers' specific outreach and intervention efforts to offer telehealth visits are crucial for dual-eligible recipients. To increase video telehealth uptake, technology access and services to rural areas should be prioritized.

Describe the population receiving orthotic/prosthetic services using telehealth in Australia, and their experience and satisfaction: a quantitative and qualitative investigation

PURPOSE

Telehealth may help meet the growing demand for orthotic/prosthetic services. Despite the resurgence of telehealth due to COVID-19, there is limited evidence to inform policy and funding decisions, nor guide practitioners.

METHODS

Participants were adult orthosis/prosthesis users or parents/guardians of child orthosis/prosthesis users. Participants were convenience sampled following an orthotic/prosthetic telehealth service. An online survey included: demographics, Telehealth Usability Questionnaire, and the Orthotic Prosthetic Users Survey - Client Satisfaction with Services. A subsample of participants took part in a semi-structured interview.

RESULTS

Most participants were tertiary educated, middle-aged, female, and lived in metropolitan or regional centres. Most telehealth services were for routine reviews. Most participants chose to use telehealth given the distance to the orthotic/prosthetic service, irrespective of whether they lived in metropolitan cities or regional areas. Participants were highly satisfied with the telehealth mode and the clinical service they received via telehealth.

While orthosis/prosthesis users were highly satisfied with the clinical service received, and the telehealth mode, technical issues affected reliability and detracted from the user experience. Interviews highlighted the importance of high-quality interpersonal communication, agency and control over the decision to use telehealth, and a degree of health literacy from a lived experience of using an orthosis/prosthesis.

Digital Health Needs and Preferences During Pregnancy and the Postpartum Period: Mixed Methods Study

BACKGROUND

Digital health is increasingly used to meet the needs of perinatal people, with estimates of pregnancy-related internet use ranging from 90% to 97% of pregnant people. As digital health takes on greater importance during the perinatal period, it is essential that providers and developers of digital health content understand why perinatal people use these resources and the features that enhance their experience. However, gaps remain in understanding the content that is most helpful and how the platforms are navigated. Learning directly from perinatal people about their needs will help ensure alignment between perinatal needs and available content.

OBJECTIVE

This formative study aims to identify the reasons why perinatal people use digital health resources; the features of the digital health platforms that are of greatest importance to them; and how these differ by perinatal stage (pregnancy vs post partum), mental health conditions, parity, and demographics (race and ethnicity).

METHODS

This mixed methods study used interviews; surveys; and secondary data on demographic, health, and pregnancy characteristics to identify the digital health needs and preferences of pregnant and postpartum people who used the Maven digital health platform in the United States during their pregnancy or postpartum period. The interviews informed the content of the surveys and provided additional insights and examples for interpreting the survey results. The surveys were used to collect data from a sample of Maven users, and the results were linked to the secondary data set. The interviews were thematically analyzed, and survey data were analyzed using descriptive statistics and stratified by parity, race, and mental health status.

RESULTS

Overall, 13 people were interviewed (including n=4, 31% pilot interviews), and 147 pregnancy and 110 postpartum survey respondents completed the surveys and had linkable secondary data. Top reasons for using digital health resources during pregnancy were to (1) know what is normal or typical during pregnancy, (2) have access to a health care provider when needed, and (3) know how the baby is developing. Top reasons for postpartum use were to (1) help with breastfeeding, (2) know what normal baby development is, and (3) help with the baby's health issues. Top platform features during pregnancy and the postpartum period were (1) credible and trustworthy information and providers, (2) nonjudgmental information and support, and (3) no cost to the user. In general, more reasons for using digital resources were identified as extremely important during pregnancy compared with post partum. The results showed minor variations across strata.

CONCLUSIONS

This formative research found minor differences in digital resource needs and preferences across user characteristics among perinatal people in the United States. Future work should examine whether there are variations in interests within topics by user characteristics, which may provide additional opportunities to better meet user needs.

How Is Telehealth Currently Being Utilized to Help in Hypertension Management within Primary Healthcare Settings? A Scoping Review

Telehealth has improved patient access to healthcare services and has been shown to have a positive impact in various healthcare settings. In any case, little is understood regarding the utilization of telehealth in hypertension management in primary healthcare (PHC) settings. This study aimed to identify and classify information about the types of interventions and types of telehealth technology in hypertension management in primary healthcare. A scoping review based on PRISMA-ScR was used in this study. We searched for articles in four databases: Pubmed, Scopus, Science Direct, and Embase in English. The selected articles were published in 2013-2023. The data were extracted, categorized, and analyzed using thematic analysis. There were 1142 articles identified and 42 articles included in this study. Regarding the proportions of studies showing varying trends in the last ten years, most studies came from the United States (US) (23.8%), were conducted in urban locations (33.3%), and had a quantitative study approach (69%). Telehealth interventions in hypertension management are dominated by telemonitoring followed by teleconsultation. Asynchronous telehealth is becoming the most widely used technology in managing hypertension in primary care settings. Telehealth in primary care hypertension management involves the use of telecommunications technology to monitor and manage blood pressure and provide medical advice and counselling remotely.

Telepsychiatry in Australia: A Scoping Review

Telepsychiatry formed part of the Australian mental health response to COVID-19, but relevant reviews pre- and post-pandemic are sparse. This scoping review aimed to map the literature on telepsychiatry in Australia and identify key research priorities. We searched databases (Medline, PubMed, PsycINFO, Scopus, Web of Science, EBSCO Psychology & Behavioral Sciences Collection, Proquest databases, and Cochrane Central Register of Controlled Trials) and reference lists from January 1990 to December 2022. Keywords included telepsychiatry, videoconferencing, telephone consultation, psychiatry, mental health, and Australia. Two reviewers independently screened titles, abstracts, and full texts. We identified 96 publications, one-third of which appeared since 2020. Extracted data included article types, service types, usage levels, outcome measures, perceptions, and research gaps. Most publications were quantitative studies (n = 43) and narrative reports of services (n = 17). Seventy-six papers reported mostly publicly established services. Videoconferencing alone was the most common mode of telepsychiatry. There was increased use over time, with the emergence of metropolitan telepsychiatry during the pandemic. Few papers used validated outcome measures (n = 5) or conducted economic evaluations (n = 4). Content analysis of the papers identified perceptions of patient (and caregiver) benefits, clinical care, service sustainability, and technology capability/capacity. Benefits such as convenience and cost-saving, clinical care issues, and implementation challenges were mentioned. Research gaps in patient perspectives, outcomes, clinical practice, health economics, usage patterns, and technological issues were identified. There is consistent interest in, and growth of, telepsychiatry in Australia. The identified perception themes might serve as a framework for future research on user perspectives and service integration. Other research areas include usage trends, outcome measures, and economic evaluation.

Digital health utilization during pregnancy and the likelihood of preterm birth

Objective

Given the complex nature of preterm birth, interventions to reduce rates of preterm birth should be multifaceted. This analysis aimed to explore the association between the duration of using Maven, a digital health platform for women's and family health, and the odds of preterm birth.

Methods

Data came from 3326 pregnant, nulliparous Maven users who enrolled in Maven during their pregnancy between January 2020 and September 2022. Chi-square and Fisher's exact tests compared characteristics between users who developed gestational conditions and users who did not. This retrospective cohort study used logistic regression models to estimate the association between the duration of Maven use and odds of preterm birth, stratified by the presence of gestational conditions.

Results

Compared to those without gestational conditions, individuals who developed gestational conditions were more likely to have a preterm birth (8.7% vs. 3.4%; p < 0.001). For every 1 h of Maven use, users experienced a 2% reduction in their odds of experiencing a preterm birth [adjusted odds ratio (AOR) (95% confidence interval (CI)) = 0.98 (0.95, 0.998), p = 0.04]. Among individuals who developed gestational conditions, every 1 h increase in Maven use was associated with a 5% reduction in the odds of experiencing a preterm birth [AOR (95% CI) = 0.95 (0.91, 0.99), p = 0.037]. There was no statistically significant association between Maven use and preterm birth in individuals without gestational conditions.

Conclusion

Among those who developed gestational conditions, use of a digital health platform was associated with a decreased likelihood of preterm birth.

Utilization of accessible resources in the fabrication of an affordable, portable, high-resolution, 3D printed, digital microscope for Philippine diagnostic applications

Philippine clinical laboratory licensing requirements mandate that diagnostic microscopy for Tuberculosis (TB) sputum microscopy, urinalysis, pap smears, wet smears, an option for complete blood count, stool exams, and malaria thick and thin smears should be accessible and available in health facilities including primary care centers. However, access to these essential diagnostics is hampered by the lack of trained personnel, relatively high costs for supplies and equipment especially in rural and underserved areas. This served as motivation for our team to utilize accessible resources in the form of affordable 3D printers, available CAD software, and components to build our low-cost Openflexure microscope (OFM) prototype. We successfully fabricated our prototype for a total of 310$ with a weight of 525g. We used pathology teaching slides from the Ateneo School of Medicine and Public Health and examined the OFM prototype imaging capabilities. The calculated image resolution was 13% higher compared to an LED light microscope sample captured by a mobile phone at 40x and 15% for 100x. The sampled slide images had adequate clarity with some identifiable cellular features for Rheumatic Heart Disease (RHD), Tuberculosis in soft tissue, and Ascariasis. We were able to correct the color aberrations of the OFM we built and was able to scan images up to 1000x magnification without using oil. Given the features and cost, the OFM prototype can be an attractive and affordable option as an alternative or augmentation to diagnostic microscopy in Philippine primary care. Moreover, it may enable telepathology to support diagnostic microscopy in frontline care.

Patient preferences for specialist outpatient video consultations: A discrete choice experiment

INTRODUCTION

Telehealth has been shown to improve access to care, reduce personal expenses and reduce the need for travel. Despite these benefits, patients may be less inclined to seek a telehealth service, if they consider it inferior to an in-person encounter. The aims of this study were to identify patient preferences for attributes of a healthcare service and to quantify the value of these attributes.

METHODS

We surveyed patients who had taken an outpatient telehealth consult in the previous year using a survey that included a discrete choice experiment. We investigated patient preferences for attributes of healthcare delivery and their willingness to pay for out-of-pocket costs.

RESULTS

Patients (n = 62) preferred to have a consultation, regardless of type, than no consultation at all. Patients preferred healthcare services with lower out-of-pocket costs, higher levels of perceived benefit and less time away from usual activities (p < 0.008). Most patients preferred specialist care over in-person general practitioner care. Their order of preference to obtain specialist care was a videoconsultation into the patient's local general practitioner practice or hospital (p < 0.003), a videoconsultation into the home, and finally travelling for in-person appointment. Patients were willing to pay out-of-pocket costs for attributes they valued: to be seen by a specialist over videoconference ($129) and to reduce time away from usual activities ($160).

CONCLUSION

Patients value specialist care, lower out-of-pocket costs and less time away from usual activities. Telehealth is more likely than in-person care to cater to these preferences in many instances.

Telemedicine Has a Social Impact: An Italian National Study for the Evaluation of the Cost-Opportunity for Patients and Caregivers and the Measurement of Carbon Emission Savings

Background: Owing to COVID-19, all stakeholders have recognized the advantages of telehealth and they were available for its permanent implementation, both from the normative and economic point of view. It is, therefore, necessary to understand what were the real benefits created in society through telehealth. Objective: Develop a method to identify a social impact of telemedicine in Italy, considering the reduction on the patient moves with a consequent travel cost, time (opportunity costs), and carbon emission savings. Methods: Since March 2020, we have conducted a quality improvement study in 17 centers, collecting sociodemographic variables. To assess the social impact, we transform the data into outcome measures. The protocol used "Telemedicina Subito" allows the rapid implementation of telemedicine, using operating manual, structured according Health Technology Assessment approach. Results: We collected data related to 2,091 televisits, analyzing three different perspectives. First, one patient with a televisit had a saving equal to the median of EUR 97.16 (interquartile range [IQR]: 64.29-159.69), USD 113.88; considering that the median cost for the visit in presence was EUR 105.91 (p-value <0.05) and after the use of telehealth had a median of EUR 0 (mean: EUR 14.70; p-value <0.05). Second, informal caregivers have a median savings of EUR 65.06 (IQR: 55.52-89.21), USD 76.26. Finally, for one single telemedicine visits we can contribute with a median carbon emission savings of ∼13 kg (IQR: 6-24). Conclusions: The evaluation of the social impact on telemedicine facilitated the creation of an important framework for decision-makers.

Clinical outcome of supervised pulmonary telerehabilitation program among adult patients with post-acute COVID-19 symptoms (PACS): A case series

Patients with post-acute COVID-19 symptoms (PACS) can present with significant sequela due to the complex systemic effects of COVID-19 infection. Most affected patients have persistent symptoms for 3-12 months after recovery from the acute phase of COVID-19. Dyspnea affecting activities of daily living is one of the most challenging symptoms and has led to an influx of pulmonary rehabilitation (PR) demand. Here we report the outcome of nine subjects with PACS who underwent 24 sessions of supervised pulmonary telerehabilitation. An improvised telerehabilitation PR was formulated to accommodate home confinement during the pandemic. Exercise capacity and pulmonary function were assessed using a cardiopulmonary exercise test, pulmonary function test, and St. George Respiratory Questionnaire (SGRQ). The clinical outcome shows improved exercise capacity on the 6-minute walk test for all patients, and most had improvement in VO2 peak and SGRQ. Seven patients improved in forced vital capacity and six in forced expiratory volume. PR is a comprehensive intervention for patients with chronic obstructive disease aimed at alleviating pulmonary symptoms and improving functional capacity. In this case series, we report its usefulness in patients with PACS and its feasibility when delivered as a supervised telerehabilitation program. Further support for the effectiveness of PR patients with PACS is mandated.

Psychological antecedents of telehealth acceptance: A technology readiness perspective

The ongoing coronavirus pandemic has been threatening the healthcare system. In this context, telehealth is a potential solution to deliver effective and safe health care to the public. To facilitate the application and acceptance of telehealth, a good understanding of psychological determinants is of great importance. Therefore, this study aims to examine the public's positive and negative mindsets towards telehealth. A theoretical model was established by employing the technology readiness model and perceived value theory. To empirically test the relationships between constructs, a total of 500 responses from residents in Singapore were collected; thereafter, structural equation modeling was performed. The results indicate that discomfort negatively impacts perceived value whereas optimism and innovativeness positively impact users' perceived value. Further, perceived value positively impacts the acceptance of telehealth via attitude. Demographic factors (i.e. internet literacy, age, education) can also influence certain aspects of technology readiness (e.g. innovativeness, optimism). Moreover, social influence is an important moderator between perceived value and the acceptance of telehealth. The empirical findings enhance the understanding of users' psychology concerning telehealth and provide policy recommendations regarding the development of telehealth to improve public health.

Association Between the Use of a Digital Health Platform During Pregnancy and Helping Users Avoid Emergency and In-Person Care: Retrospective Observational Study

BACKGROUND

Almost one-third of pregnant people visit the emergency room during pregnancy. Although some emergency care is necessary, gaps in patient education and inaccessibility of preventive services have been identified as key reasons for high-cost, low-value care in pregnancy. Digital platforms present a promising solution for providing resources to supplement routine prenatal care, thereby reducing the use of low-value in-person services.

OBJECTIVE

This study aimed to describe the relationship between the use of Maven and in-person care avoidance (emergency room or office visits) during pregnancy. Maven is a digital prenatal health platform that supplements routine prenatal care. Maven offers educational content (articles, videos, and classes), care coordination (through a care advocate), and provider services (web-based appointments and communication with providers) designed to complement prenatal care. Specifically, the aims of this study were to examine whether the use of Maven is associated with in-person care avoidance overall and whether improvements in pregnancy-related knowledge facilitate in-person care avoidance. To assess aim 2, we tested if the use of Maven is associated with improvements in self-reported understanding of warning signs and medically accurate information and if self-reported understanding of medically accurate information and warning signs is associated with in-person care avoidance in a population of Maven users.

METHODS

In this retrospective study, we used adjusted logistic regression to examine the relationship between digital platform use, avoidance of in-person care, and the platform's influence on pregnancy-related knowledge (learning medically accurate information and recognizing warning signs). Demographics, medical history, and in-person care avoidance were self-reported.

RESULTS

Of the 5263 users, 280 (5.32%) reported that Maven helped them avoid in-person care during pregnancy. More users who reported avoiding in-person care also reported that the digital platform helped them understand warning signs (231/280, 82.5%) and learned medically accurate information (185/280, 66.1%). In the adjusted models, all modes of digital service use (assessed as quartiles) were associated with avoiding in-person care in a dose-response manner (eg, web-based provider appointments: Q2 adjusted odds ratio [aOR] 1.57, 95% CI 1.00-2.41; Q3 aOR 2.53, 95% CI 1.72-3.72; Q4 aOR 5.26, 95% CI 3.76-7.42). Users were more likely to avoid in-person care if they reported that Maven helped them recognize warning signs (aOR 3.55, 95% CI 2.60-4.94) or learn medically accurate information (aOR 2.05, 95% CI 1.59-2.67).

CONCLUSIONS

These results suggest that digital platforms can be effective in helping patients to avoid in-person care. The educational pathway suggests that digital platforms can be particularly effective in helping patients recognize warning signs and learn medically accurate information, which may help them avoid in-person care by recognizing when in-person care is medically appropriate. Future work is needed to assess other pathways through which digital resources can support pregnant people and improve perinatal care use.

Procedure-Based Telehealth Utilization in General Surgery

The authors hypothesize that standardized telehealth (TH) scheduling processes will improve TH utilization without increasing adverse events. Fifty visits preimplementation and 67 visits postimplementation were audited from June 2021 to January 2022. Both leadership and frontline stakeholders were engaged to identify current workflows and potential interventions targeting outpatient elective procedures. Process mapping outlined current TH scheduling workflows. Outcomes related to TH completion, cost, and TH scheduling were collected after implementation. Preimplementation TH scheduling rate was 32%. The intervention required TH postoperative appointments to be scheduled in clinic at the time of surgery scheduling with TH being the default postsurgical appointment for a standardized list of eligible procedures. Following implementation, 95% of patients undergoing eligible procedures had TH follow-up. This provided improved access to surgical follow-up care, by reducing travel needs to the Veterans Affairs facility. Secondarily, this intervention increased clinic appointment availability and resulted in possible increased revenue for billable visits. Standardizing TH scheduling based on the procedure improves the utilization of TH resulting in improved clinic efficiency and increased revenue, without increasing adverse events.

TeleNEwCARe: An Italian case-control telegenetics study in patients with Hereditary NEuromuscular and CArdiac diseases

Telemedicine provides healthcare services remotely and represents a fundamental resource for the management of rare and fragile patients. Tele-health implementation is a main objective of the European Reference Networks (ERNs) mission to accelerate diagnosis for rare diseases. TeleNewCAre is a pilot case-control project which evaluates the efficacy and satisfaction of telegenetics for neuromuscular and cardiac adult patients, compared to face-to-face genetic counselling. The virtual sessions were co-hosted by a medical geneticist and a neurologist/cardiologist. Specific questionnaires (Clinical Genetics Satisfaction Questionnaire (CGS), Telemedicine Satisfaction Questionnaire (TSQ) and a Satisfaction Questionnaire for medical geneticists) were used to assess the effectiveness and fulfilment of telecounselling, both for patients and health care providers. Satisfaction expressed for telegenetics did not significantly differ from face-to-face counselling. The virtually enrolled patients declared they had the possibility to relate confidentially with the specialists, to share information and to be informed in an exhaustive way about their disease. Almost all patients declared themselves willing to reuse the telecounselling in the future. The multidisciplinary care was perceived as a significant added value. No overt technical problems were reported although the need for digital skills and tools can limit patients' compliance. Our experience supports telegenetics as a valid alternative to traditional genetic counselling in cardiac and neuromuscular patients. This innovative approach facilitates multidisciplinary care, grants a periodical follow up, without forcing patients to discomfortable travelling, and allows to maintain expert care. This result meets the ERNs needs to reduce patients' burden to access and monitor their healthcare.

How COVID-19 Broke the Barriers Related to the Implementation of Telecare-Patients' Experiences with a New form of Providing Health Services in Primary Health Care

BACKGROUND

The COVID-19 pandemic has significantly contributed to accelerating the development of telemedicine and eHealth. The main aim of this study was to assess the attitudes of patients towards remote care implemented in general practice (GP) during the pandemic.

METHODS

The study was a pilot study conducted in March-April 2021, considering technical aspects of using teleconsultations, and evaluating the difficulties, advantages and disadvantages for patients. When assessing opinions, a simple Likert scale was used, where a value of 1 meant the worst possible assessment or strong disagreement and the upper value the best or full agreement of the respondent.

RESULTS

The study covered 408 respondents. Their biggest organizational challenge reaching GPs by telephone, regardless of the patients' home location (p = 0.23698). Obtaining e-documents was not problematic but was rated as worse by men (p = 0.048295). Respondents rated the overall effectiveness of teleconsultations more highly if they could speak directly with a doctor (p = 0.0005). There were no differences in willingness to recommend teleconsultations based on gender (p = 0.2432), place of residence (p = 0.7878), age (p = 0.290355) or education (p = 0.9109), but people assessing the overall effectiveness of telemedicine more highly were more willing to recommend it (p = 0.000).

CONCLUSIONS

Respondents assess teleconsultations in a differentiated way, noticing both positive and negative features of the remote form of providing health services.

Synchronous Home-Based Telemedicine for Primary Care: A Review

Synchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate.

In-Person Versus Video Preoperative Visit: A Randomized Clinical Trial

IMPORTANCE

This study further supports virtual visits for gynecologic preoperative care.

OBJECTIVES

The objective of this study was to determine if preoperative video visits are noninferior to in-person visits in pelvic reconstructive surgery. Secondary objectives are as follows: patient satisfaction, convenience, visit duration, total perioperative visits, and patient travel time/distance.

STUDY DESIGN

Noninferiority randomized-controlled trial of patients undergoing pelvic reconstructive surgery randomized to in-person or video counseling. The primary outcome was a composite score on the Preoperative Preparedness Questionnaire.

RESULTS

Demographics were similar except for higher body mass index (BMI) in the video group (29.5 vs 26.3; P = 0.01), and fewer patients in the video group used text messaging for health care delivery (40.7% vs 59.3%, P = 0.04). Video visits were noninferior to in-person visits in Preoperative Preparedness Questionnaire scores (62.5 ± 4.6 vs 63.0 ± 3.6; difference = 0.5; 95% confidence interval, -0.8, □). There was no difference in "strongly agree" response to question 11, "Overall, I feel prepared for my upcoming surgery" (79.6% vs 88.9%, P = 0.19). Satisfaction was higher for video visits based on composite Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey scores (31.3 ± 1.5 vs 30.5 ± 2, P = 0.02). Video visits were more convenient (100% vs 85.2%, P < 0.01), of shorter duration for patients (39.3 ± 14.0 minutes vs 55.9 ± 18.9 minutes; P < 0.01), and similar length for health care providers (28.8 ± 9.6 minutes vs 28.2 ± 9.8 minutes; P = 0.77). The video visit group had fewer office visits (2.0 vs 3.0, P < 0.01) and traveled 66 minutes ( P < 0.01) and 28 miles ( P < 0.01) less.

CONCLUSION

Preoperative video visits are noninferior to in-person visits for preparing patients for pelvic reconstructive surgery.

Acceptability and Comfort Regarding Remotely Delivered PrEP Services in Mississippi

Despite the prevalence of human immunodeficiency virus (HIV) in Mississippi, access to pre-exposure prophylaxis (PrEP) is mostly limited to urban areas. Remote PrEP care via telemedicine, HIV self-testing, and prescription mail delivery can improve care in underserved communities. This mixed methods study assessed the acceptability and feasibility of using remote PrEP care, compared to alternatives. This consisted of (1) a cross-sectional survey and (2) interviews. PrEP-eligible adults were recruited from community-based organizations across Mississippi while accessing HIV testing between December 2019 and May 2022. Those surveyed (n = 63) indicated the greatest comfort in receiving PrEP via mail delivery (m = 5.14) and telemedicine (m = 4.89) and least comfort at gyms (m = 3.92). Comfort significantly differed between mail delivery and gyms (F = 2.90; P < .01). Those interviewed (n = 26) expressed relatively high comfort with remote PrEP care citing enhanced accessibility, privacy, simplicity, and quality. Remote PrEP services were acceptable and feasible among our sample, thus, should be expanded in Mississippi to address unmet needs.

A Telehealth and Telepsychiatry Economic Cost Analysis Framework: Scoping Review

Introduction: Despite a good evidence base for telepsychiatry (TP), economic cost analyses are infrequent and vary in quality. Methods: A scoping review was conducted based on the research question, "From the perspective of an economic cost analysis for telehealth and telepsychiatry, what are the most meaningful ways to ensure a study/intervention improved clinical care, provided value to participants, had population level impact, and is sustainable?" The search in seven databases focused on keywords in four concept areas: (1) economic cost analysis, (2) evaluation, (3) telehealth and telepsychiatry, and (4) quantifiable health status outcomes. The authors reviewed the full-text articles based on the inclusion (Medical Subject Headings [MeSH] of the keywords) and exclusion criteria. Results: Of a total of 2,585 potential references, a total of 99 articles met the inclusion criteria. The evaluation of telehealth and TP has focused on access, quality, patient outcomes, feasibility, effectiveness, outcomes, and cost. Cost-effectiveness, cost-benefit, and other analytic models are more common with telehealth than TP studies, and these studies show favorable clinical, quality of life, and economic impact. A standard framework for economic cost analysis should include: an economist for planning, implementation, and evaluation; a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost-benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); broad perspective (e.g., societal perspective); sensitivity analysis for uncertainty in modeling; and adjustments for differential timing (e.g., discounting and future costs). Conclusions: Technology assessment and economic cost analysis-such as effectiveness and implementation science approaches-contribute to clinical, training, research, and other organizational missions. More research is needed with a framework that enables comparisons across studies and meta-analyses.

Exploring Adult Patients’ Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review

The COVID-19 pandemic transformed a gradual uptake of telemedicine, into a sudden worldwide implementation of telemedicine consultations. Primary care is a particular area affected and one where telemedicine consultations are expected to be the future. However, for effective long-term implementation it is vital that patient perceptions and experiences are understood. The aim of this qualitative systematic review was to explore the perceptions and experiences of adults who have used telemedicine consultations in primary care. Studies were identified through a search of four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) alongside reference list and citation searches. Quality assessment was conducted using the CASP checklist and data was synthesized using a simplified approach to thematic analysis. From 2492 identified records, ten studies met the eligibility criteria all of which were judged as either good or moderate quality. Three themes were identified which were potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes, sixteen sub-themes were identified with examples including accessibility and convenience for potential benefits, lack of face-to-face interaction and impersonal consultations for potential barriers, and continuity of care for beneficial prerequisites. Analysing these subthemes, four main recommendations for practice can be made which are to utilise continuity of care, offer both video and telephone consultations, provide adequate support, and that healthcare professionals should demonstrate an explicit understanding of the patient’s health issues. Further research is needed to explore and expand on this topic area and future research should be viewed as a continuous process.

Physicians' satisfaction with telehealth services among family physicians in Cluster 1 hospitals

Background

Physicians are increasingly applying telehealth services in the hospital. The use of telehealth services helps to ensure that doctors treat patients and write prescriptions remotely without the need to meet physically with the patient.

Methods

The study used a descriptive survey design, in which collection and sampling of data were standardized to represent the population of all physicians. The target population was all doctors in all private healthcare systems, King Saud Medical City (KSMC), and four hospitals in the southwest area of Saudi Arabia. Data were collected via a simple random sampling system and engaged questionnaires. Microsoft Office Excel was used for data entry and preparation of graphs and charts.

Results

We collected data from 151 physicians in Cluster 1 hospitals. Most were males (74.8%) with a mean age of 31.14 years. Of these, 57.6% thought that telemedicine saved physicians' traveling time, 27.8% were satisfied with telemedicine services, 28.5% were not satisfied, and 43.7% were neutral; 61.6% thought that telemedicine was important for them, and 53.6% liked using telemedicine because of the similarity of participants' values and society values underlying its uses; 59.6% reported that telemedicine improved their job effectiveness and performance, while 58.9% reported that telemedicine enabled them to accomplish tasks more quickly and made them more productive.

Conclusion

Physicians expressed a high level of satisfaction and a positive attitude toward telemedicine. Future researches are essential to see how attitudes about telemedicine have altered since the pandemic.

Teleconsultation in health and social care professions education: A systematic review

Introduction

Teleconsultation education in health care and social work education is under‐reported. However, literature indicates that educating the workforce in teleconsultation skills is essential to continue with safe, high‐quality delivery of services and increases the likelihood of implementing teleconsultations in health care. Training for students should, therefore, be encouraged. This systematic literature review aims to investigate global experiences of teleconsultation training in undergraduate health care and social work education.

Methods

A systematic review of peer‐reviewed literature was undertaken. The review was guided by the Joanna Briggs Institute guidelines. Electronic databases were searched for eligible evidence. Studies were included only if they described and evaluated teleconsultation education for undergraduate health care and social work students.

Results/Discussion

This review shows that mandatory education in teleconsultation is limited in undergraduate health care and social work education. Narrative synthesis and analysis of 14 studies led to the development of two themes: pedagogical aspects, and perspectives on telecommunication and teleconsultation learning and teaching. Practical experiences with simulated patients or during clinical placements with real patients were the most common mode of delivery. Feedback on teleconsultation education was generally positive; overall, health care students felt more confident using teleconsultation and valued safety of learning through simulation.

Conclusion

Teleconsultation education is a legitimate way to expose students to telehealth. High satisfaction rates, increased knowledge and confidence in use indicate the positive impact this learning has on students. Nevertheless, further high‐quality research and guidance for educators are warranted.

Pursuing Connectivity in Cardio-Oncology Care-The Future of Telemedicine and Artificial Intelligence in Providing Equity and Access to Rural Communities

The aim of this review is to discuss the current health disparities in rural communities and to explore the potential role of telehealth and artificial intelligence in providing cardio-oncology care to underserviced communities. With advancements in early detection and cancer treatment, survivorship has increased. The interplay between cancer and cardiovascular disease, which are the leading causes of morbidity and mortality in this population, has been increasingly recognized. Worldwide, cardio-oncology clinics (COCs) have emerged to deliver a multidisciplinary approach to the care of patients with cancer to mitigate cardiovascular risks while minimizing interruptions in cancer treatment. Despite the value of COCs, the accessibility gap between urban and rural communities in both oncology and cardio-oncology contributes to health care disparities and may be an underrecognized determinant of health globally. Telehealth and artificial intelligence offer opportunities to provide timely care irrespective of rurality. We therefore explore current developments within this sphere and propose a novel model of care to address the disparity in urban vs. rural cardio-oncology using the experience in Canada, a geographically large country with many rural communities.

Implementation of telemedicine preoperative visits for abortion procedures through 18 weeks gestation at a Northern California hospital-based center

OBJECTIVE

Describe the implementation of a preoperative telemedicine program at a Northern California hospital-based center for abortion procedures requiring cervical preparation.

STUDY DESIGN

We implemented a pilot program using telemedicine for preoperative visits for patients needing cervical preparation prior to an abortion procedure from 12 to 18 weeks. We required ultrasonography for gestational age documentation in addition to placental localization in patients with a prior cesarean delivery. We prescribed misoprostol for cervical preparation for patients undergoing the telemedicine preoperative visit; in-person preoperative visits typically involve placement of osmotic dilators. Secondarily, we surveyed patients who had telemedicine and in-person preoperative visits to compare their preoperative experiences.

RESULTS

Implementation required eight months of multidisciplinary meetings. From March 2018 through March 2019, we received 200 abortion referrals at 12 to 18 weeks gestation. Of these 200 patients, 119 did not meet telemedicine eligibility criteria, most commonly due to inability to obtain required ultrasonography (n=89 [75%]). Of the remaining 81 patients, 43 scheduled telemedicine visits of which 41 initiated and 38 (88%) completed the visits. Twenty-one (55%) telemedicine encounters had no or minor technical difficulties. Thirty-one of 34 (91%) telemedicine and 91 of 108 (84%) in-person visit patients expressed high satisfaction with their preoperative appointment (p=0.4); none reported dissatisfaction. Patients chose the telemedicine visit primarily for convenience and transportation concerns.

CONCLUSION

A multidisciplinary team is essential for the successful implementation of a preoperative telemedicine program for procedural abortion care. Patients reported high satisfaction and reduced logistical burdens with the telemedicine option.

IMPLICATIONS

Telemedicine preoperative visits for abortion procedures at 12-18 weeks gestation may improve access to abortion care, reduce patient burdens, and provide an alternative encounter option which may improve the patient experience.

Implementation of telehealth during COVID-19: Implications for providing behavioral health services to pediatric patients

The coronavirus pandemic and in-person contact restrictions necessitated rapid implementation of telehealth, specifically videoconferencing, to provide essential care to patients. This study surveyed 25 pediatric behavioral health providers at a single center during their first month of utilizing telehealth during coronavirus disease 2019 (COVID-19). Twenty-one participants completed a pre-questionnaire distributed prior to telehealth service delivery, and 23 providers completed a post-questionnaire approximately three weeks later. Results indicate the majority of behavioral health providers had no experience providing telehealth services prior to COVID-19. The majority of participating behavioral health providers utilized telehealth to provide pediatric patient care within the first month of access to telehealth. Participants' confidence in their ability to provide telehealth services significantly increased within the first month of implementation, regardless of previous training in telehealth. This study identified differences between anticipated and actual barriers to treatment, with technological issues identified as the largest actual barrier to service delivery. Participants indicated a preference for in-person service delivery, which they reported allows for better rapport-building, behavioral observations, reduced technological barriers, and fewer distractions. However, most participants reported they intend to continue utilizing telehealth for certain types of behavioral health services (e.g., diagnostic interviews and outpatient therapy) after the pandemic has subsided.

A 3-Item Measure of Digital Health Care Literacy: Development and Validation Study

BACKGROUND

With increased reliance on digital health care, including telehealth, efficient and effective ways are needed to assess patients' comfort and confidence with using these services.

OBJECTIVE

The goal of this study was to develop and validate a brief scale that assesses digital health care literacy.

METHODS

We first developed an item pool using existing literature and expert review. We then administered the items to participants as part of a larger study. Participants were caregivers of children receiving care at a pediatric clinic who completed a survey either on the web or over the telephone. We randomized participants into development and confirmatory samples, stratifying by language so that exploratory factor analysis and confirmatory factor analysis could be performed with separate samples of participants. We assessed the scale's validity by examining its associations with participants' demographics, digital access, and prior digital health care use.

RESULTS

Participants (N=508) were, on average, aged 34.7 (SD 7.7) years, and 89.4% (454/508) were women. Of the 508 participants, 280 (55.1%) preferred English as their primary language, 157 (30.9%) preferred Spanish, and 71 (14%) preferred Arabic; 228 (45%) had a high school degree or less; and 230 (45.3%) had an annual household income of

CONCLUSIONS

Despite the potential for digital health care to improve quality of life and clinical outcomes, many individuals may not have the skills to engage with and benefit from it. Moreover, these individuals may be those who already experience worse outcomes. A screening tool such as the Digital Health Care Literacy Scale could be a useful resource to identify patients who require additional assistance to use digital health services and help ensure health equity.

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Key Words

• digital health care
• digital literacy
• health equity
• mobile phone
• scale development
• telehealth

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MESH Headings Collapse

Grants

• K12 HL137943 NHLBI NIH HHS
• U54 MD010722 NIMHD NIH HHS

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Affiliation(s)

Lyndsay A Nelson Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
Jacquelyn S Pennings Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, United States
Evan C Sommer Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
Filoteia Popescu Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
Shari L Barkin Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States

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Patient and provider experience with virtual care in a large, ambulatory care hospital in Ontario, Canada during the COVID-19 pandemic: An observational study (Preprint)

Background

Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear.

Objective

We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care.

Methods

Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses.

Results

During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99).

Conclusions

Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.

Lung Function Tests, Quality of Life and Telemedicine: Three Windows on the Multifaceted World of Asthma in Adolescents

Asthma is a heterogeneous disease usually characterized by chronic airway inflammation and recognized as the most prevalent chronic illness among children. Despite this, the knowledge as to how asthma affects adolescents is still scarce. One of the main management problems of asthmatic adolescents is the poor adherence to pharmacological and non-pharmacological treatments. The assessment of respiratory function and the impact on quality of life are still two crucial challenges in the management of asthmatic adolescents. Additionally, the COVID-19 pandemic has prompted physicians to explore complementary management strategies including telemedicine technologies. This review aims to provide an update on the contribution of respiratory functional tests, how asthma affects quality of life of adolescents and, finally, how telemedicine contributes to the management of adolescent asthmatics during the COVID-19 pandemic.

eHealth, telehealth, and telemedicine in the management of the COVID-19 pandemic and beyond: Lessons learned and future perspectives

In this article, we discuss evidence supporting the effective implementation of eHealth, telehealth, and telemedicine during the coronavirus disease 2019 pandemic, with a view towards its permanent future integration in healthcare. We performed a literature search for articles describing the use of telehealth/ telemedicine in the pandemic context using five databases. The articles selected describe the use of telemedicine as its advantages in terms of practicality and cost-effectiveness. This synthesis of articles is applicable to high-, middle- and low-income countries. Some of the notable benefits include breaking down geographical and time barriers, reducing waiting lists and crowding in healthcare facilities, and saving on national healthcare expenditure. However, there are a number of difficulties with the widespread implementation of telemedicine services that mainly relate to bureaucratic and regulatory concerns. Moreover, it is also important to make healthcare professionals and providers aware of the limits of this tool to avoid potential cases of negligence. Patients in turn will have to be made aware of and be educated on the use of this new healthcare modality before it is accepted by them. In the current socio-economic climate, it is therefore essential to implement a telehealth model aimed at efficiency and continuity of healthcare, as well as leading to an improvement in the quality of life of patients, whilst optimising existing resources and reducing costs. In that regard, the adoption of eHealth, telehealth, and telemedicine services should be considered highly timely, despite current existing limitations.

Exploring Telehealth Readiness in a Resource Limited Setting: Digital and Health Literacy among Older People in Rural India (DAHLIA)

An ageing population, disproportionally affecting developing countries, increases demand on healthcare systems. Digital health offers access to healthcare for older people, particularly those residing in rural areas, as is the case for 71% of older adults in India. This research examined technology uptake and digital and health literacy (eHEALS) among a sample of 150 older adults in rural Mysore and Suttur, India. The study utilised mixed-method, with descriptive analysis of quantitative data and thematic analysis of qualitative data. Low rates of digital (11%) and health literacy (3-27% across domains) were identified. Mobile phone ownership was 50%, but very few owned or used a smartphone and less than 10% used the Internet to contact health professionals. Qualitative analysis found low technology usage, driven by limited exposure and confidence in using digital devices. Barriers to usage included poor traditional literacy and physical aspects of ageing like poor vision. Social support from neighbours, family and local primary healthcare staff may enable adoption of digital health. Access to healthcare through digital means among Indian rural older adults needs to consider low rates of both digital and health literacy and leverage the value of support from family and primary healthcare providers.

Telehealth Adoption and Discontinuation by US Hospitals: Results From 2 Quasi-Natural Experiments

Background

Prior US hospital telehealth (video visit) studies have focused on describing factors that influence telehealth adoption or performance effects for specific patient segments, hospital systems, or geographic regions. To our knowledge, a larger-scale, national-level (US) study has yet to be conducted on the causal impacts of hospital telehealth adoption as well as discontinuation.

Objective

The aim of this study is to understand the causal impact of US hospital telehealth adoption or discontinuation on hospital performance from 2016 to 2018.

Methods

We analyzed impacts of telehealth adoption or discontinuation by US hospitals on emergency department visits, total ambulatory visits (minus emergency department visits), outpatient services revenue, total facility expenses, and total hospital revenue for the 2016-2018 period. We specifically focused on performance effects for hospitals that switched from not having telehealth to adopting telehealth, or vice versa, during the 2016-2018 period, thus exploiting 2 quasi-natural experiments. We applied a difference-in-differences research design to each of the 2 main analyses. We compared hospitals that have made a telehealth change to groups of hospitals with similar characteristics that did not make a telehealth change, which established a counterfactual. To appropriately match hospitals between treatment and control groups, we applied propensity score matching. Our primary data were from the American Hospital Association Annual Survey and the Healthcare Cost Report Information System data. Several control variables were obtained from additional sources, including the Area Health Resource File and the Federal Communications Commission.

Results

We found that telehealth adoption by US hospitals during the 2016-2018 period resulted in, on average, an increased number of total ambulatory visits (P=.008), increased total facility expenses (P<.001), and increased hospital revenue (P=.004) compared with the control group. We found that telehealth discontinuation during the same period resulted in, on average, decreased outpatient services revenue (P=.02) compared with the control group.

Conclusions

Our findings suggest that telehealth adoption increases use but has mixed impacts on performance, given that cost and revenue increase. However, once telehealth is offered, removing it can have a negative impact on performance, implying that returning to prior performance levels, if telehealth is removed, may be challenging.

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

Review of Systematic Reviews in the Field of Telemedicine

Background: Although the systematic reviews regarding telemedicine have increased in recent decades, no comprehensive studies have been conducted to review these systematic reviews. The present study aimed to review the published systematic reviews regarding telemedicine applications for the report and appraisal of several aspects. Methods: The literature search was performed in the PubMed database for the systematic reviews published during January 2010-June 2020 in the field of telemedicine using "telemedicine" Mesh terms. The extracted data from the selected articles were the year of publication, telemedicine specialty, clinical outcomes, cost evaluation, and satisfaction assessment. Data analysis was performed using descriptive statistics. Results: Among 746 retrieved articles, 191 cases were selected and reviewed. Most of the studies were focused on telemedicine (n=35; 18.3%), followed by telerehabilitation (n=22; 11.5%), tele-diabetes (n=18; 9.4%), telecardiology (n=16; 8.3%), home telecare (n=13; 6.8%), telepsychiatry (n=12; 6.3%), teledermatology (n=11; 5.7%), and teleneurology (n=9; 4.7%). The selected studies were primarily focused on clinical outcomes (72.7%), followed by cost-effectiveness (32.4%) and user satisfaction (29.3%). In addition, they mostly indicated that telemedicine services yielded acceptable clinical outcomes (72.5%), cost-effectiveness (67.7%), and healthcare provider/patient satisfaction (83.9%). Conclusion: Although telerehabilitation, tele-diabetes, telecardiology, home telecare, and telepsychiatry were studied further, there are still some specific specialties such as teleradiology, telepathology, and telepediatric that should be considered more. Moreover, investigation of various outcomes could result in a more comprehensive view of this field. Therefore, further investigations in this regard would improve telemedicine applications and encourage potential telemedicine providers to initiate these applications.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services.

CONTEXT

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits.

METHODS

We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance.

FINDINGS

We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services.

CONCLUSIONS

There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.