The tragic paradoxical effect of telemedicine on healthcare disparities- a time for redemption: a narrative review

Exploring the potential of telemedicine for improved primary healthcare in India: a comprehensive review

Telemedicine is a promising solution to the challenges of delivering equitable and quality primary healthcare, especially in LMICs. This review evaluated peer-reviewed literature on telehealth interventions in Indian primary care published from Jan 1, 2011 to Dec 31, 2021, from PubMed, Scopus, TRIP, Google Scholar, Indian Kanoon, and Cochrane database The majority of Indian studies focus on key health issues like maternal and child health, mental health, diabetes, infectious diseases, and hypertension, mainly through patient education, monitoring, and diagnostics. Yet, there's a lack of research on telemedicine's cost-effectiveness, communication among providers, and the role of leadership in its quality and accessibility. The current research has gaps, including small sample sizes and inconsistent methodologies, which hamper the evaluation of telemedicine's effectiveness. India's varied healthcare landscape, technological limitations, and social factors further challenge telemedicine's adoption. Despite regulatory efforts, issues like the digital divide and data privacy persist. Addressing these challenges with a context-aware, technologically driven approach is crucial for enhancing healthcare through telemedicine in India.

A Systematic Review and Bayesian Network Meta-Analysis Comparing In-Person, Remote, and Blended Interventions in Physical Activity, Diet, Education, and Behavioral Modification on Gestational Weight Gain among Overweight or Obese Pregnant Individuals

BACKGROUND

Despite the well-documented adverse outcomes associated with obesity during pregnancy, this condition remains a promising modifiable risk factor.

OBJECTIVES

The aim of this study was to ascertain the most effective treatment modalities for gestational weight gain (GWG) in pregnant women classified as overweight or obese.

METHODS

A systematic search was conducted across 4 electronic databases: Embase, EBSCOhost, PubMed, and Web of Science. To assess the quality of evidence, the Confidence In Network Meta-Analysis (CINeMA) approach, grounded in the Grading of Recommendations Assessment, Development, and Evaluation framework, was employed. A Bayesian network meta-analysis was conducted to synthesize the comparative effectiveness of treatment modalities based on GWG outcomes.

RESULTS

The analysis incorporated 60 randomized controlled trials, encompassing 16,615 participants. Modes of intervention administration were classified as remote (R: eHealth [e] and mHealth [m]), in-person (I), and a combination of both (I+R). The interventions comprised 5 categories: education (E), physical activity (PA), dietary (D), behavior modification (B), and combinations thereof. The quality of the evidence, as evaluated by CINeMA, ranged from very low to high. Compared to the control group, the I-D intervention (mean difference [MD]: -1.27; 95% confidence interval [CI]: -2.23, -0.32), I-PADB (MD: -0.60, 95% CI: -1.19, -0.00), and I-B (MD: -0.34, 95% CI: -0.57, -0.10) interventions showed significant efficacy in reducing GWG.

CONCLUSIONS

Preliminary findings suggest that the I-D intervention is the most efficacious in managing GWG among pregnant women who are overweight or obese, followed by I-PADB and I-B+R-B(m) treatments. These conclusions are drawn from evidence of limited quality and directness, including insufficient data on PA components used in the interventions. Owing to the absence of robust, direct evidence delineating significant differences among various GWG management strategies, it is tentatively proposed that the I-D intervention is likely the most effective approach. This study was registered with PROSPERO as CRD42023473627.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Can You Hear Me Now? Patient Perceptions of Telehealth in a Rural Primary Care Population

Background: The COVID-19 pandemic significantly increased telehealth adoption. Rural communities experience challenges relating to telehealth, including a shortage of clinicians, low health literacy, mistrust of medicine, and limited technology access, yet rural perceptions have not been a subject of robust study. The setting of this study was a rural Midwestern family medicine clinic within an academic health system. Methods: Surveys were given to all patients of age 18 or older visiting the clinic over a one-week period. Those who expressed interest were contacted for a semistructured interview. Descriptive statistics and chi-square testing were used to analyze survey results for significant relationships, while interview transcripts were analyzed for themes. Results: Of respondents, 27% indicated prior telehealth use and were more likely to prefer telehealth visits (p = 0.03). Perceptions of telehealth were sorted into themes, including scope of care, convenience, and technology. Telehealth was preferred for discussing test results or mental health. Barriers such as travel time and transportation access favored telehealth. Although more convenient, telehealth was found to be less effective for relationship building. The absence of physical examination during phone visits was a concern. Phone visits were more prevalent due to failure of video-based technology. Conclusions: Despite the potential to address these unique challenges in rural communities, telehealth acceptance is poor. Barriers such as accessibility of technology can be improved through governmental and health systemwide measures. Future work can help develop interventions that counter negative perceptions of telehealth while increasing interest and uptake in rural communities.

Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials

In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.

Will the United States pass on telemedicine progress?

Background

During the COVID-19 pandemic, federal and state health policies allowed temporary flexibilities for Medicare and Medicaid beneficiaries, leading to a sharp increase in telemedicine use. However, many of the flexibilities that enabled innovation and growth in telemedicine continue temporarily since the federal emergency declaration ended in May 2023, and the United States has not made permanent decisions about telemedicine policy. Analysts have raised concerns about increased spending, program integrity, safety, and equity, and recommend strengthening oversight.

Methods

Here, we argue that we must continue the flexibilities to better understand telemedicine's quality, safety, and outcomes, and until the United States can develop an evidence-based digital health strategy. A premature regression to pre-pandemic telemedicine policies risks unintended consequences.

Conclusion

We must continue the current policy flexibilities, safeguard against fraud and abuse, and immediately prioritize research and evaluation of telemedicine's quality, safety, and outcomes, to avoid unintended consequences and support more permanent policy decision-making.

Awareness, Knowledge, Attitude, and Skills (AKAS) of Telemedicine and Its Use by Primary Healthcare Providers

Background

This study aimed to determine the rate of telemedicine (TM) use and the levels of awareness, knowledge, attitude, and skills of TM among primary healthcare (PHC) providers.

Methods

In a cross-sectional study, 104 PHC providers were subjected to a validated AKAS scale via Survey Monkey. The tool consists of 4 parameters that users can respond to using a 4-point Likert scale to assess their awareness (12 statements), knowledge (11 statements), attitude (11 statements), and skills (13 statements) on TM. Total and percentage mean scores (PMS) were calculated for each parameter. Participants were categorized in each parameter into three categories: low (≤ 49% score), average (50-70% score), and high (≥ 71% score) levels. The association of AKAS levels with personal characteristics and TM use was investigated. The significance was set at p<0.05.

Results

One-half of participants (51%) reported current use of TM, and two-thirds (63.5%) reported a high level of AKAS, with a PMS of 72.9±14.7, 95% CI: 70.1-75.7. There were significant associations between the following: years of experience and levels of knowledge (Χ2LT = 6.77, p= 0.009) and skills (Χ2LT = 4.85, p = 0.028), respectively; and total household income and levels of skills (Χ2LT = 6.91, p= 0.009). The rate of TM use was significantly associated with awareness levels (Χ2LT = 6.14, p = 0.013). Lack of training ranked as the first barrier (45.5%), followed by connection problems and tools' unavailability (35.1% each). The participants recommended providing TM training (41.1%) and stabilization of connection and networking signals (30.1%).

Conclusion

Despite their high level of TM awareness, the rate of TM use by PHC providers is less than satisfactory. Establishing standardized TM training and supporting the network signals are recommended. A large-scale study on the impact of TM integration with PHC services is necessary.

A Comprehensive Review on Exploring the Impact of Telemedicine on Healthcare Accessibility

Telemedicine has emerged as a transformative force in healthcare delivery, particularly in improving healthcare accessibility. This comprehensive review examines the impact of telemedicine on healthcare accessibility, exploring its ability to overcome geographical, financial, sociocultural, and infrastructural barriers to healthcare access. Through remote consultations, monitoring, and diagnosis facilitated by technology, telemedicine extends healthcare reach to remote and underserved areas while enhancing temporal accessibility with round-the-clock availability. By streamlining healthcare delivery systems, telemedicine reduces costs and promotes efficiency, ultimately fostering health equity and improving health outcomes. However, technological barriers, regulatory hurdles, and patient acceptance remain. To realize telemedicine's full potential, collaboration among stakeholders in the healthcare and technology sectors is imperative. Policymakers must enact supportive regulations, healthcare providers must integrate telemedicine into their practices, and technology companies must innovate to develop user-friendly platforms. Through concerted efforts, telemedicine can catalyze advancing healthcare accessibility and enhance the health and well-being of individuals worldwide.

Telemedicine, e-Health, and Digital Health Equity: A Scoping Review

Background

With the progressive digitization of people's lives and in the specific healthcare context, the issue of equity in the healthcare domain has extended to digital environments or e-environments, assuming the connotation of "Digital Health Equity" (DHE). Telemedicine and e-Health, which represent the two main e-environments in the healthcare context, have shown great potential in the promotion of health outcomes, but there can be unintended consequences related to the risk of inequalities. In this paper, we aimed to review papers that have investigated the topic of Digital Health Equity in Telemedicine and e-Health [definition(s), advantages, barriers and risk factors, interventions].

Methods

We conducted a scoping review according to the methodological framework proposed in PRISMA-ScR guidelines on the relationship between Digital Health Equity and Telemedicine and e-Health via Scopus and Pubmed electronic databases. The following inclusion criteria were established: papers on the relationship between Digital Health Equity and Telemedicine and/or e-Health, written in English, and having no time limits. All study designs were eligible, including those that have utilized qualitative and quantitative methods, methodology, or guidelines reports, except for meta-reviews.

Results

Regarding Digital Health Equity in Telemedicine and e-Health, even if there is no unique definition, there is a general agreement on the idea that it is a complex and multidimensional phenomenon. When promoting Digital Health Equity, some people may incur some risk/s of inequities and/or they may meet some obstacles. Regarding intervention, some authors have proposed a specific field/level of intervention, while other authors have discussed multidimensional interventions based on interdependence among the different levels and the mutually reinforcing effects between all of them.

Conclusion

In summary, the present paper has discussed Digital Health Equity in Telemedicine and e-Health. Promoting equity of access to healthcare is a significant challenge in contemporary times and in the near future. While on the one hand, the construct "equity" applied to the health context highlights the importance of creating and sustaining the conditions to allow anyone to be able to reach (and develop) their "health potential", it also raises numerous questions on "how this can happen". An overall and integrated picture of all the variables that promote DHE is needed, taking into account the interdependence among the different levels and the mutually reinforcing effects between all of them.

Digitalization in orthopaedics: a narrative review

Advances in technology and digital tools like the Internet of Things (IoT), artificial intelligence (AI), and sensors are shaping the field of orthopaedic surgery on all levels, from patient care to research and facilitation of logistic processes. Especially the COVID-19 pandemic, with the associated contact restrictions was an accelerator for the development and introduction of telemedical applications and digital alternatives to classical in-person patient care. Digital applications already used in orthopaedic surgery include telemedical support, online video consultations, monitoring of patients using wearables, smart devices, surgical navigation, robotic-assisted surgery, and applications of artificial intelligence in forms of medical image processing, three-dimensional (3D)-modelling, and simulations. In addition to that immersive technologies like virtual, augmented, and mixed reality are increasingly used in training but also rehabilitative and surgical settings. Digital advances can therefore increase the accessibility, efficiency and capabilities of orthopaedic services and facilitate more data-driven, personalized patient care, strengthening the self-responsibility of patients and supporting interdisciplinary healthcare providers to offer for the optimal care for their patients.

Digital determinants of health as a way to address multilevel complex causal model in the promotion of Digital health equity and the prevention of digital health inequities: A scoping review

Background

With the progressive digitization of health services and the current spread of Telemedicine and e-Health, it became clear that promoting Digital health equity (DHE) is necessary to support health potential, to avoid that some individuals can incur in unintended inequities. In this paper, we address the complex causal process(es) that may generate risk of inequities, considering the so-called "Digital Determinants of health" (DDoH) and their relationship with determinants of health (DoH).

Design and methods

We conducted a scoping review, according to methodological framework proposed in PRISMA-ScR guidelines, on the definition of DDoH (Scopus, Pubmed and Web of Science electronic databases). Inclusion criteria: papers on the definition of DDoH, no time limits, all study designs eligible.

Results

There is an agreement on the link between DDoHs and "digital divide" and on their effects on a wide range of health, functioning outcomes, both as barriers and as facilitators. Authors proposed to modify or integrate with DDoHs the "Rainbow model" or other conceptual models on DoH. To promote DHE, authors suggest considering a multidimensional complex causal model, with interdependence among the different levels and the mutually reinforcing effects.

Conclusion

To study DDoH and their relationship with main determinants of health could be a way to address the complex causal model in the promotion of DHE. However, as they act in a multidimensional causal context, any intervention may consider the interdependence among different involved levels, within them, and the mutually reinforcing effects. Further research is needed to gain a more complete picture of the field.

Navigating the Immune Maze: Pioneering Strategies for Unshackling Cancer Immunotherapy Resistance

Cancer immunotherapy has ushered in a transformative era in oncology, offering unprecedented promise and opportunities. Despite its remarkable breakthroughs, the field continues to grapple with the persistent challenge of treatment resistance. This resistance not only undermines the widespread efficacy of these pioneering treatments, but also underscores the pressing need for further research. Our exploration into the intricate realm of cancer immunotherapy resistance reveals various mechanisms at play, from primary and secondary resistance to the significant impact of genetic and epigenetic factors, as well as the crucial role of the tumor microenvironment (TME). Furthermore, we stress the importance of devising innovative strategies to counteract this resistance, such as employing combination therapies, tailoring immune checkpoints, and implementing real-time monitoring. By championing these state-of-the-art methods, we anticipate a paradigm that blends personalized healthcare with improved treatment options and is firmly committed to patient welfare. Through a comprehensive and multifaceted approach, we strive to tackle the challenges of resistance, aspiring to elevate cancer immunotherapy as a beacon of hope for patients around the world.