UK paediatric speech and language therapists' perceptions on the use of telehealth in current and future clinical practice: An application of the APEASE criteria

BACKGROUND

Telehealth for paediatric speech and language therapy became one of the most salient modes of service delivery during the COVID-19 pandemic. Evidence for speech and language therapy services via telehealth in comparison to face-to-face delivery demonstrates promising outcomes, and studies have begun to explore practitioner and client experiences. However, across the literature, many critical elements of services are overlooked, and there is a need to frame the evidence base within a theoretical model that can draw out practical implications that consider the range of factors having an impact on clinical implementation in real-world contexts. The APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria offer such a model. The current study explored practising UK speech and language therapists' (SLTs) clinical experience of telehealth through the lens of the APEASE criteria and aimed to identify recommendations for future service provision from the practitioner perspective.

METHODS

An online survey structured using the APEASE criteria was developed in collaboration with the UK Royal College of Speech and Language Therapists. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using reflexive thematic analysis.

RESULTS

Four hundred and thirty-eight qualified and practicing UK paediatric SLTs completed the survey. Telehealth was broadly acceptable and practicable to SLTs yet there remains some uncertainty about its efficacy and cost-effectiveness compared to face-to-face interventions and how equitable it is for different population groups. SLTs reported that effective implementation of telehealth services was dependent upon several contextual factors; affordability was a perceived barrier to clients having access to telehealth resources, intervention via telehealth was perceived as more acceptable than assessment, and whilst many SLTs welcomed aspects of telehealth, there were concerns about the physical and mental health consequences for practitioners. Six themes for the future development of telehealth in paediatric speech and language therapy were identified: (1) balanced and tailored services; (2) technology and equipment; (3) information and communication; (4) capacity building; (5) monitoring and evaluation; and (6) leadership and governance.

CONCLUSIONS

Outcomes highlight promising, concerning and uncertain aspects of telehealth in paediatric speech and language therapy. SLTs value a flexible and tailored approach to service delivery and recommend that effective leadership, clear communication, ongoing policy and guidance development, upskilling of users and careful evaluation of impact are required to ensure optimal implementation. The APEASE criteria offer a valuable opportunity to enhance and streamline practice and research to ensure sustainable implementation of telehealth in the paediatric speech and language therapy services of tomorrow.

WHAT THIS PAPER ADDS

What is already known on this subject The COVID-19 pandemic led to the increased use of telehealth as a main mode of service delivery in paediatric speech and language therapy. Pre-COVID-19, evidence for the use of telehealth in this field included small-scale experimental studies that reported on children with particular disorders and explored telehealth outcomes in comparison to face-to-face delivery. The realities of at-scale clinical practice were not well-represented, and critical elements of service such as cost-effectiveness were often overlooked in the paediatric literature. Furthermore, despite emerging global evidence for temporary telehealth responses to the crisis in speech and language therapy, the long-term and future use of telehealth remains unclear. What this paper adds to existing knowledge The current study applied the lens of the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria, which were used in this case to consider socioeconomic, ecological and cultural factors to capture an overarching understanding of the use of telehealth in paediatric speech and language therapy, and to inform the role of telehealth in future, longer-term and at-scale service development. Results indicated emerging trends in UK paediatric speech and language therapists' (SLTs') perceptions of telehealth and SLTs perceived a hybrid approach to service delivery, combining mostly face-to-face services with some telehealth, was likely to continue in the future. We identified six themes to guide the future development of telehealth in paediatric speech and language therapy services: (1) balanced and tailored services; (2) technology and equipment; (3) information and communication; (4) capacity building; (5) monitoring and evaluation; and (6) leadership and governance. What are the potential or actual clinical implications of this work? UK SLTs believe that speech and language therapy services using telehealth should be reflective, tailored and flexible to meet the requirements and circumstances of the children, young people and families served, as well as the physical and emotional needs of practitioners. SLTs recommend that this service development is clearly communicated to all stakeholders and suggested that those using telehealth should be supported through appropriate training, and ongoing effectiveness should be monitored. Telehealth is here to stay and the APEASE criteria offer a unique opportunity to ensure sustainable models of service delivery; to support co-ordinated leadership at the local, national and international levels and the development of policy and clinical guidance.

Primary mode of communication for people with total laryngectomy in the UK: a cross-sectional survey

OBJECTIVE

This study aimed to report on the UK rate of surgical voice restoration usage and investigate the factors that influence its uptake.

METHOD

A national multicentre audit of people with total laryngectomy was completed over a six-month period (March to September 2020) in response to the coronavirus disease 2019 pandemic. This study is a secondary analysis of the data collected, focusing on the primary communication methods used by people with total laryngectomy.

RESULTS

Data on surgical voice restoration were available for 1196 people with total laryngectomy; a total of 852 people with total laryngectomy (71 per cent) used surgical voice restoration. Another type of communication method was used by 344 people. The factors associated with surgical voice restoration in the multiple regression analysis were sex (p = 0.003), employment (employed vs not employed, p < 0.001) and time post-laryngectomy (p < 0.001).

CONCLUSION

This study provides an important benchmark for the current status of surgical voice restoration usage across the UK. It found that 71 per cent of people with total laryngectomy used surgical voice restoration as their primary communication method.

Telehealth Interventions in Head and Neck Cancer Patients: A Systematic Review

BACKGROUND

Head and neck cancer (HNC) and its treatments often result in adverse effects that impair a patient's quality of life. Although intensive rehabilitative strategies can be used, their applicability can be limited due to patient-specific and socioeconomic barriers. Telehealth interventions represent a possible novel approach to increase access to these services and improve posttreatment quality of life in the HNC population.

OBJECTIVE

The objective of this systematic review was to identify studies investigating telemedicine-based interventions for HNC patients to determine whether there is a consensus concerning the cost-effectiveness, clinical utility, and accessibility of this model for rehabilitation.

METHODS

PubMed, EMBASE, Web of Science, and CINAHL were used to identify literature without time limit for publication. A critical appraisal of individual sources was conducted by 2 reviewers. Sixteen studies met inclusion criteria.

RESULTS

Studies related to telehealth interventions in the HNC population are limited. Salient themes included feasibility of telehealth as an intervention, effects on self-management and knowledge, impact on quality of life, physical and psychiatric symptoms, and cost.

CONCLUSION

Although the current literature presents promising data, indicating that telehealth interventions may be both effective and cost-efficient in the management of HNC patients, more research is needed to definitively elucidate their role in management.

IMPLICATIONS FOR PRACTICE

Telehealth interventions are valuable for clinicians as an alternative to expand access to care across the cancer continuum, to strengthen patients' knowledge and consequently their self-management, and to provide continuity of services as well as for remote monitoring of symptoms and response to treatment.

Use of a Telerehabilitation Platform in a Stroke Continuum: A Qualitative Study of Patient and Therapist Acceptability

The purpose of this study was to describe the acceptability of a stroke telerehabilitation platform from the perspective of both patients and therapists. Two public rehabilitation centers participated in a pilot telerehabilitation trial. A theoretical framework was used to conceptualize acceptability. Semi-structured individual interviews with patients and focus groups of therapists were conducted. Most participants and therapists were satisfied with the intervention. Participants emphasized the advantages of staying at home to get their treatments. Therapists were more skeptical at first about their self-efficacy to deliver therapy remotely. There was a consensus among therapists about the need for a combination of telerehabilitation and in-person visits to optimize treatments. While we found overall good acceptability, effectiveness of this technology could be improved via an accessible user interface, complementary rehabilitation material, and ongoing training and technical just-in-time support with therapists.

Two-sided perspective on tele-speech therapy: Experiences of stuttering patients, and their parents

The purpose of this study was to investigate the benefits and challenges of the tele-speech therapy from the perspective of patients who stutter, and their parents. Semi-structured interviews were conducted with 12 patients and three parents in two rehabilitation centers. Data were analyzed using a qualitative content analysis approach proposed by Graneheim and Lundman. Seven categories were determined: accessible treatment, motivation of comfort in tele-speech therapy, challenges of tele-therapy, satisfaction, virtual competency, lower quality compared to face-to-face therapy, and uncertainty about the effectiveness of tele-speech therapy. The participants had a two-sided perspective regarding tele-speech therapy. Positive experiences included benefitting from more qualified therapists at multiple locations, faster access to treatment, and saving cost and time. Negative experiences and challenges consisted of low-quality of technology infrastructure for rehabilitation including low quality of shared images and videos, ineffective communication, insufficient sympathy, indirect communication, and technology incompetency. Findings showed that the participants were interested in the application of tele-speech therapy, as this method could increase their accessibility and provide the opportunity to choose proper therapists. The determined benefits and challenges can provide the policy-makers with beneficial information to implement tele-speech therapy.

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part II): Reliability and Validity in Healthy Elderly Individuals and Oral Cancer Patients

In our prior published study, we extracted evaluation items suitable for remote administration, and made a relatively simple Remote Examination of Deglutition (RED). This study aimed at verifying the reliability and validity of RED. The participants were 21 healthy elderly individuals and 72 postoperative oral cancer (OC) patients. OC patients underwent videofluoroscopic dysphagia examination, and severity was judged on the dysphagia severity scale (DSS). Reliability and validity of RED were examined in all participants under face-to-face conditions, in comparison with the Mann Assessment of Swallowing Ability (MASA). Reliability and validity of remote administration of RED were examined in 40 participants. ROC curves were used to find cut-off RED scores to predict aspiration and deglutition disorders. The Cronbach's alpha coefficient for the items was 0.882. There was a high correlation between the total score of RED and MASA in the face-to-face condition. When RED score was compared among different severity groups (DSS1-4, DSS5-6, and DSS7), the total and oral preparatory stage scores revealed significant group differences. The area under the curve (AUC) for aspiration based on the ROC curve was 0.913, with a sensitivity/specificity of 0.80/0.98. The AUC for deglutition disorders was 0.819, with a sensitivity/specificity of 0.74/0.67. In both face-to-face and remote conditions, the reliability of RED was good.The reliability and validity of RED were confirmed. RED has shown the potential to assess the likelihood of aspiration and deglutition disorders in OC patients remotely as an initial assessment tool.

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.

Effectiveness of Telerehabilitation on Motor Impairments, Non-motor Symptoms and Compliance in Patients With Parkinson's Disease: A Systematic Review

Introduction: Parkinson's disease (PD) is a chronic neurodegenerative disease involving a progressive alteration of the motor and non-motor function. PD influences the patient's daily living and reduces participation and quality of life in all phases of the disease. Early physical exercise can mitigate the effects of symptoms but access to specialist care is difficult. With current technological progress, telemedicine, and telerehabilitation is now a viable option for managing patients, although few studies have investigated the use of telerehabilitation in PD. In this systematic review, was investigated whether telerehabilitation leads to improvements in global or specific motor tasks (gait and balance, hand function) and non-motor dysfunction (motor speech disorder, dysphagia). The impact of TR on quality of life and patient satisfaction, were also assessed. The usage of telerehabilitation technologies in the management of cognitive impairment was not addressed.

Method: An electronic database search was performed using the following databases: PubMed/MEDLINE, COCHRANE Library, PEDro, and SCOPUS for data published between January 2005 and December 2019 on the effects of telerehabilitation systems in managing motor and non-motor symptoms. This systematic review was conducted in accordance with the PRISMA guideline and was registered in the PROSPERO database (CRD42020141300).

Results: A total of 15 articles involving 421 patients affected by PD were analyzed. The articles were divided into two categories based on their topic of interest or outcome. The first category consisted of the effects of telerehabilitation on gait and balance (3), dexterity of the upper limbs (3), and bradykinesia (0); the second category regarded non-motor symptoms such as speech disorders (8) and dysphagia (0). Quality of life (7) and patient satisfaction (8) following telerehabilitation programs were also analyzed, as well as feasibility and costs.

Conclusion: Telerehabilitation is feasible in people affected by PD. Our analysis of the available data highlighted that telerehabilitation systems are effective in maintaining and/or improving some clinical and non-clinical aspects of PD (balance and gait, speech and voice, quality of life, patient satisfaction).

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020141300.

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part I): Selection of Examination Items

In order to ensure appropriateness and feasibility of examination items for remote evaluation for deglutition disorders, a questionnaire based on the Delphi method was administered to 122 speech–language–hearing therapists (STs), and a set of examination items was selected. The participants were instructed to view a video recording of a remote assessment situation and answer a 30-item questionnaire. Of 19 items ensuring the appropriateness for deglutition disorders detection, 13 items ultimately met the consensus criteria for remote feasibility. Factor analysis extracted three factors: ‘oral observation,’ ‘overall evaluation,’ and ‘perceptual voice judgment.’ In free-text responses, “quality and stability of the voice that may be heard through the device” were the most common concerns, followed by “the need to correct of the camera angle, magnification, and targets that should be projected,” “concerns about the technical aspects of the assistants and their role in relation with the examiner/ST,” and “the need for palpation as well as visual confirmation.” The proposed 13-item examination is considered to capture the characteristics of deglutition disorders, while items that appeared difficult to implement remotely were excluded. The fact that some items could be influenced by the video calling experience when judging the feasibility of remote implementation, the acceptability of such items, is likely to increase in the future.

Objective and Subjective Clinical Swallowing Outcomes via Telehealth: Reliability in Outpatient Clinical Practice

Purpose The COVID-19 pandemic has drastically increased the use of telehealth. Prior studies of telehealth clinical swallowing evaluations provide positive evidence for telemanagement of swallowing. However, the reliability of these measures in clinical practice, as opposed to well-controlled research conditions, remains unknown. This study aimed to investigate the reliability of outcome measures derived from clinical swallowing tele-evaluations in real-world clinical practice (e.g., variability in devices and Internet connectivity, lack of in-person clinician assistance, or remote patient/caregiver training). Method Seven raters asynchronously judged clinical swallowing tele-evaluations of 12 movement disorders patients. Outcomes included the Timed Water Swallow Test (TWST), Test of Masticating and Swallowing Solids (TOMASS), and common observations of oral intake. Statistical analyses were performed to examine inter- and intrarater reliability, as well as qualitative analyses exploring patient and clinician-specific factors impacting reliability. Results Forty-four trials were included for reliability analyses. All rater dyads demonstrated "good" to "excellent" interrater reliability for measures of the TWST (intraclass correlation coefficients [ICCs] ≥ .93) and observations of oral intake (≥ 77% agreement). The majority of TOMASS outcomes demonstrated "good" to "excellent" interrater reliability (ICCs ≥ .84), with the exception of the number of bites (ICCs = .43-.99) and swallows (ICCs = .21-.85). Immediate and delayed intrarater reliability were "excellent" for most raters across all tasks, ranging between ICCs of .63 and 1.00. Exploratory factors potentially impacting reliability included infrequent instances of suboptimal video quality, reduced camera stability, camera distance, and obstruction of the patient's mouth during tasks. Conclusions Subjective observations of oral intake and objective measures taken from the TWST and the TOMASS can be reliably measured via telehealth in clinical practice. Our results provide support for the feasibility and reliability of telehealth for outpatient clinical swallowing evaluations during COVID-19 and beyond. Supplemental Material https://doi.org/10.23641/asha.13661378.

Telehealth for Dysphagia Across the Life Span: Using Contemporary Evidence and Expertise to Guide Clinical Practice During and After COVID-19

Purpose Our aim was to critically review recent literature on the use of telehealth for dysphagia during the COVID-19 pandemic and enhance this information in order to provide evidence- and practice-based clinical guidance during and after the pandemic. Method We conducted a rapid systematized review to identify telehealth adaptations during COVID-19, according to peer-reviewed articles published from January to August 2020. Of the 40 articles identified, 11 met the inclusion criteria. Full-text reviews were completed by three raters, followed by qualitative synthesis of the results and description of practical recommendations for the use of telehealth for dysphagia. Results Seven articles were guidelines articles, three were editorials, and one was a narrative review. One article focused on telehealth and dysphagia during COVID-19. The remaining 10 mentioned telehealth in varying degrees while focusing on dysphagia management during the pandemic. No articles discussed pediatrics in depth. The most common procedure for which telehealth was recommended was the clinical swallowing assessment (8/11), followed by therapy (7/11). Six articles characterized telehealth as a second-tier service delivery option. Only one article included brief guidance on telehealth-specific factors, such as legal safeguards, safety, privacy, infrastructure, and facilitators. Conclusions Literature published during the pandemic on telehealth for dysphagia is extremely limited and guarded in endorsing telehealth as an equivalent service delivery model. We have presented prepandemic and emerging current evidence for the safety and reliability of dysphagia telemanagement, in combination with practical guidelines to facilitate the safe adoption of telehealth during and after the pandemic.

Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice

Purpose This document outlines initial recommendations for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. Method The authors initially developed these recommendations by adapting those developed for physical therapists working with patients with COVID-19 by Thomas et al. (2020). The recommendations then underwent review by 14 speech-language pathologists and rehabilitation-focused academics representing seven countries (Belgium, Brazil, Canada, Ireland, Japan, New Zealand, the United States). The authors consolidated and reviewed the feedback in order to decide what should be included or modified. Applicability to a global audience was intended throughout the document. Results The authors had 100% agreement on the elements of the recommendations that needed to be changed/modified or added. The final document includes recommendations for speech-language pathology workforce planning and preparation, caseload management, service delivery and documentation, as well as recommendations for the selection of appropriate personal protective equipment and augmentative and alternative communication equipment in the acute care hospital setting. Conclusions Speech-language pathologists play a critical role in the assessment, management, and treatment of patients with COVID-19. Several important considerations need to be made in order to meet the needs of this unique patient population. As more is learned about the impact of the virus on swallowing and communication, the role of the speech-language pathologist on interdisciplinary care teams will remain paramount.

Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic

At the time of writing this paper, there are over 11 million reported cases of COVID-19 worldwide. Health professionals involved in dysphagia care are impacted by the COVID-19 pandemic in their day-to-day practices. Otolaryngologists, gastroenterologists, rehabilitation specialists, and speech-language pathologists are subject to virus exposure due to their proximity to the aerodigestive tract and reliance on aerosol-generating procedures in swallow assessments and interventions. Across the globe, professional societies and specialty associations are issuing recommendations about which procedures to use, when to use them, and how to reduce the risk of COVID-19 transmission during their use. Balancing safety for self, patients, and the public while maintaining adequate evidence-based dysphagia practices has become a significant challenge. This paper provides current evidence on COVID-19 transmission during commonly used dysphagia practices and provides recommendations for protection while conducting these procedures. The paper summarizes current understanding of dysphagia in patients with COVID-19 and draws on evidence for dysphagia interventions that can be provided without in-person consults and close proximity procedures including dysphagia screening and telehealth.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Developing the system architecture for conducting synchronous paediatric feeding assessments via telepractice

Introduction

Telepractice systems should be acceptable to users and meet end-user needs. Whilst the system requirements to conduct adult dysphagia assessments via telepractice are established, key differences exist between adult and paediatric swallowing assessments. This study was conducted to develop the system architecture required to conduct paediatric feeding assessments in patient homes via telepractice.

Methods

The study used a four-phase iterative design, informed by human-centred design principles. In Phase 1, two telepractice researchers and two paediatric feeding clinicians identified assessment tasks and explored potential system design solutions. Initial system testing was completed using clinical simulations (Phase 2). Live trials with 10 typically developing children were then conducted (Phase 3). Phase 4 involved user-centred feedback from clinicians and parents. Feedback from the development team, clinicians and parents was used to continuously refine the model.

Results

A combination of synchronous and asynchronous methods enabled all assessment components to be successfully completed. Clinician and parent feedback established the optimal technology (e.g. phone, tablet) and key camera positions necessary to optimise visual/auditory information for the online clinician. End-user feedback identified greater time efficiencies could be achieved through collecting some data (e.g. intra-oral pictures) via asynchronous methods prior to the session. Information sheets were deemed necessary to enhance the user experience. Clinicians and parents responded positively to the final system design.

Discussion

Modifications to standard videoconferencing were necessary to develop a clinically viable process for conducting paediatric feeding assessments in the home via telepractice. End-user feedback was integral to the design of the final model.

Adding navigation, artificial audition and vital sign monitoring capabilities to a telepresence mobile robot for remote home care applications

A telepresence mobile robot is a remote-controlled, wheeled device with wireless internet connectivity for bidirectional audio, video and data transmission. In health care, a telepresence robot could be used to have a clinician or a caregiver assist seniors in their homes without having to travel to these locations. Many mobile telepresence robotic platforms have recently been introduced on the market, bringing mobility to telecommunication and vital sign monitoring at reasonable costs. What is missing for making them effective remote telepresence systems for home care assistance are capabilities specifically needed to assist the remote operator in controlling the robot and perceiving the environment through the robot's sensors or, in other words, minimizing cognitive load and maximizing situation awareness. This paper describes our approach adding navigation, artificial audition and vital sign monitoring capabilities to a commercially available telepresence mobile robot. This requires the use of a robot control architecture to integrate the autonomous and teleoperation capabilities of the platform.

Home-based telehealth service for swallowing and nutrition management following head and neck cancer treatment

Introduction

Following (chemo)radiotherapy (C/RT) for head and neck cancer (HNC), patients return to hospital for regular outpatient reviews with speech pathology (SP) and nutrition and dietetics (ND) for acute symptom monitoring, nutritional management, and swallowing and communication rehabilitation. The aim of the current study was to determine the feasibility of a home-based telehealth model for delivering SP and ND reviews, to provide patients with more convenient access to these appointments.

Methods

Service outcomes, costs, and consumer satisfaction were examined across 30 matched participants: 15 supported via the standard model of care (SMOC), and 15 via the home-based telehealth model of care (TMOC).

Results

All patients were successfully managed via telehealth. The TMOC was more efficient, with a reduced number ( p < 0.003) and duration ( p < 0.01) of appointments required until discharge. Significant patient cost savings ( p = 0.002) were reported for the TMOC due to decreased travel requirements. While staff costs were reduced, additional telehealth equipment levies resulted in a lower but non-significant overall cost difference to the health service when using the TMOC. High satisfaction was reported by all participants attending the TMOC.

Discussion

The findings support the feasibility of a home-based telehealth model for conducting SP and ND reviews post C/RT for HNC.

Telehealth Stroke Dysphagia Evaluation Is Safe and Effective

Background: Rapid evaluation of dysphagia poststroke significantly lowers rates of aspiration pneumonia. Logistical barriers often significantly delay in-person dysphagia evaluation by speech language pathologists (SLPs) in remote and rural hospitals. Clinical swallow evaluations delivered via telehealth have been validated in a number of clinical contexts, yet no one has specifically validated a teleswallow evaluation for in-hospital post-stroke dysphagia assessment. Methods: A team of 6 SLPs experienced in stroke care and a telestroke neurologist designed, implemented, and tested a teleswallow evaluation for acute stroke patients, in which 100 patients across 2 affiliated, urban certified stroke centers were sequentially evaluated by a bedside and telehealth SLP. Inter-rater reliability was analyzed using percent agreement, Cohen's kappa, Kendall's tau-b, and Wilcoxon matched-pairs signed rank tests. Logistic regression models accounting for age and gender were used to test the impact of stroke severity and stroke location on agreement. Results: We found excellent agreement for both liquid (91% agreement; kappa = 0.808; Kendall's tau-b = 0.813, p < 0.001; Wilcoxon signed rank = -0.818, p = 0.417) and solid (87% agreement; kappa = 0.792; Kendall's tau-b = 0.844, p < 0.001; Wilcoxon signed rank = 0.243, p = 0.808) dietary textures. From regression modeling, there is suggestive but inconclusive evidence that higher National Institute of Health Stroke Scale (NIHSS) scores correlate with lower levels of agreement for liquid diet recommendations (OR [95% CI] 0.895 [0.793-1.01]; p = 0.07). There was no impact of NIHSS score for solid diet recommendations and no impact of stroke location on solid or liquid diet recommendations. Qualitatively, we identified professional, logistical, technical, and patient barriers to implementation, many of which resolved with experience over time. Conclusions: Dysphagia evaluation by a remote SLP via telehealth is safe and effective following stroke. We plan to implement teleswallow across our multistate telestroke network as standard practice for poststroke dysphagia evaluation.

Telehomecare telecommunication framework - from remote patient monitoring to video visits and robot telepresence

Over the last few years, the number of remote patient monitoring (RPM) products and of videoconferencing systems has exploded. There is also a significant number of research initiatives addressing the use of service robots for assistance in daily living activities. From a technological standpoint, providing telehomecare services is certainly feasible. However, one technological barrier is to have access to a telecommunication platform that can be adapted to address the broad range of specifications and requirements of clinical and telehealth applications. Handling the full spectrum of possibilities requires a telecommunication framework that can transmit vital sign data from patients to clinicians, bidirectional audio-video from a standard computing device, and also multiple video streams and bidirectional transmission of control data. This paper presents a framework that integrates such capabilities. It also illustrates the versatility of the framework by presenting custom-designed devices allowing integration of capabilities ranging from RPM to video visits and robot telepresence.

Randomized controlled trial of a multisite speech pathology telepractice service providing swallowing and communication intervention to patients with head and neck cancer: Evaluation of service outcomes

BACKGROUND

The purpose of this study was to present our evaluation of a new speech pathology telepractice service supporting the swallowing and communication management of patients with head and neck cancer.

METHODS

A multicenter randomized controlled trial was conducted within a large public cancer service. Referrals from speech pathologists at 3 regional sites (spoke sites) were managed by a specialist clinician from a cancer center (hub site) either via standard care (phone/email support/appointments at the hub site) or a newly established telepractice service (online consultation between the hub site and spoke site).

RESULTS

Eighty-two referrals (39 for standard care and 43 for telepractice care) were managed. Service efficiency favoring the telepractice model was reported with a significant reduction in the number (p = .004) and duration (p = .024) of contact events required to manage the referrals. Higher consumer and clinician satisfaction was also reported for the telepractice service.

CONCLUSION

A speech pathology telepractice service benefits both the patient and health provider through higher service efficiency and treatment satisfaction. © 2017 Wiley Periodicals, Inc. Head Neck 39: 932-939, 2017.

Telehealth for Dysphagia Rehabilitation: The Present and the Future

Dysphagia affects about nine million adults and half a million children annually in the United States alone, and its prevalence is only projected to increase as the baby boomer generation grows older. For many individuals who live in rural or underserved areas, accessing a speech-language pathologist (SLP) with expertise in dysphagia can be challenging. Telehealth appears to be a viable solution to address the needs of individuals living in these areas, and for patients and clinicians with mobility/access limitations. This article provides an overview of the current research evidence in dysphagia telehealth and identifies research and clinical practice gaps as well as potential solutions. Our aim is to provide foundational knowledge for dysphagia clinicians who are interested in entering the telehealth arena.

A scoping review of Australian allied health research in ehealth

Background

Uptake of e-health, the use of information communication technologies (ICT) for health service delivery, in allied health appears to be lagging behind other health care areas, despite offering the potential to address problems with service access by rural and remote Australians. The aim of the study was to conduct a scoping review of studies into the application of or attitudes towards ehealth amongst allied health professionals conducted in Australia.

Methods

Studies meeting inclusion criteria published from January 2004 to June 2015 were reviewed. Professions included were audiology, dietetics, exercise physiology, occupational therapy, physiotherapy, podiatry, social work, and speech pathology. Terms for these professions and forms of ehealth were combined in databases of CINAHL (EBSCO), Cochrane Library, PsycINFO (1806 – Ovid), MEDLINE (Ovid) and AMED (Ovid).

Results

Forty-four studies meeting inclusion criteria were summarised. They were either trials of aspects of ehealth service delivery, or clinician and/or client use of and attitudes towards ehealth. Trials of ehealth were largely from two research groups located at the Universities of Sydney and Queensland; most involved speech pathology and physiotherapy. Assessments through ehealth and intervention outcomes through ehealth were comparable with face-to-face delivery. Clinicians used ICT mostly for managing their work and for professional development, but were reticent about its use in service delivery, which contrasted with the more positive attitudes and experiences of clients.

Conclusion

The potential of ehealth to address allied health needs of Australians living in rural and remote Australia appears unrealised. Clinicians may need to embrace ehealth as a means to radicalise practice, rather than replicate existing practices through a different mode of delivery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1791-x) contains supplementary material, which is available to authorized users.

Examining user perceptions of SwallowIT: A pilot study of a new telepractice application for delivering intensive swallowing therapy to head and neck cancer patients

Consumer feedback and end-user perceptions provide important information regarding the clinical acceptability of new telepractice systems. This pilot investigation aimed to evaluate end-user perceptions of a new asynchronous telepractice application, ‘ SwallowIT’, designed to support patients to remotely complete intensive swallowing therapy during curative chemoradiotherapy (CRT) treatment for head and neck cancer (HNC). Insights were sought from 15 patients with oropharyngeal cancer who used SwallowIT to complete supported home swallowing therapy. Perceptions were evaluated via structured questionnaires, completed following initial orientation to SwallowIT and on completion of CRT. Semi-structured phone interviews were conducted ≥3 months post-treatment. The majority of patients reported positive initial perceptions towards SwallowIT for comfort (87%), confidence (87%), motivation (73%) and support (87%). No statistically significant change in perceptions was observed from baseline to end of CRT ( p > 0.05). Thematic analysis of interviews revealed four main themes: the ease of use of SwallowIT, motivating factors, circumstances which made therapy difficult, and personal preferences for service-delivery models. These preliminary findings demonstrate that SwallowIT was well-perceived by the current group of HNC consumers and suggest that SwallowIT may be well-accepted as an alternate service-delivery model for delivering intensive swallowing therapy during CRT.

Usability in telemedicine systems-A literature survey

INTRODUCTION

The rapid development of sensors and communication technologies enable the growth of new innovative services in healthcare, such as Telemedicine. An essential ingredient in the development of a telemedicine system and its final acceptance by end users are usability studies. The principles of usability engineering, evaluations and telemedicine are well established, and it may contribute to the adoption and eventually deployment of such systems and services. An in-depth usability analysis, including performance and attitude measures, requires knowledge about available usability techniques, and is depending on the amount of resources. Therefore it is worth investigating how usability methods are applied in developing telemedicine systems. Our hypothesis is: with increasing research and development of telemedicine systems, we expect that various usability methods are more equally employed for different end-user groups and applications.

METHOD

A literature survey was conducted to find telemedicine systems that have been evaluated for usability or ease of use. The elements of the PICO framework were used as a basis for the selection criteria in the literature search. The search was not limited by year. Two independent reviewers screened all search results first by title, and then by abstract for inclusion. Articles were included up to May 2015.

RESULTS

In total, 127 publications were included in this survey. The number of publications on telemedicine systems significantly increased after 2008. Older adults and end-users with cardiovascular conditions were among largest target end-user groups. Remote monitoring systems were found the most, in 90 publications. Questionnaires are the most common means for evaluating telemedicine systems, and were found in 88 publications. Questionnaires are used frequently in studies focusing on cardiovascular diseases, Parkinson's disease and older adult conditions. Interviews are found the most in publications related to stroke. In total 71% of the publications were trial-orientated and the remaining process orientated. An increase in telemedicine research, development and applications is found worldwide, with the majority of publications conducted in America.

DISCUSSION AND CONCLUSION

Monitoring patients in their homes can lead to better healthcare at lower costs which implies an increased demand of new healthcare strategies like telemedicine. We expected that with the increase in telemedicine research and development, a greater range of usability methods would also be employed in the included publications. This is not the case. Researchers employed questionnaires as a preferred usability method for each type of telemedicine system and most end-users. However, in process-orientated studies a greater range of usability evaluations were applied, with fewer differences found in the amount of publications for each evaluation method. Questionnaires enable researchers to evaluate a system quickly on end users, as it requires less expertise on the evaluation method compared to the other methods. They are easily distributed and are customizable. The use of questionnaires is therefore an evaluation method of choice for a variety of telemedicine systems and end-users.

A systematic review of the use of telehealth in speech, language and hearing sciences

Introduction

We conducted a systematic literature review to investigate the domain of speech-language and hearing sciences (SLHS) in telehealth.

Methods

The databases used for the literature search were Web of Knowledge, Pubmed, Scopus, Embase and Scielo. The inclusion criteria consisted of papers published up to August 2014. Papers without peer-review evaluation, and those without abstracts or available full texts were excluded.

Results

A total of 103 papers were selected. The selected studies have focused primarily on hearing (32.1%), followed by speech (19.4%), language (16.5%), voice (8.7%), swallowing (5.8%), multiple areas (13.6%) and others (3.9%). The majority of the studies focused on assessment (36.9%) or intervention (36.9%). The use of telehealth in SLHS has been increasing in many countries, especially in the last 5 years. The country with the largest number of published studies was the United States of America (32.03%), followed by Australia (29.12%). The remaining studies were distributed in lower numbers among other countries.

Discussion

The advancement of information and communication technologies provides more favourable conditions for providing distance care in several areas. Most of studies concluded that the telehealth procedure had advantages over the non-telehealth alternative approach (85.5%); however, 13.6% reported that it was unclear whether the telehealth procedure had advantages. Some barriers still need to be overcome, such as technology, training, regulation, acceptance and recognition of the benefits of this practice by the public and professionals. The need for speech-language pathologists and audiologists to adapt to this new health care modality is evident.

Impact of dysphagia severity on clinical decision making via telerehabilitation

OBJECTIVE

Recent research supports the proposal that valid and reliable clinical swallow examinations (CSEs) can be conducted via telerehabilitation. However, no studies have explored whether dysphagia severity has an impact on the success of the session or its outcomes. The current study examined how dysphagia severity impacted on either (a) clinical decision making for safety of oral intake or (b) clinician perceptions of CSEs conducted via telerehabilitation.

SUBJECTS AND METHODS

One hundred patients (25 nondysphagics and 25 mild, 25 moderate, and 25 severe dysphagics) were assessed using a telehealth system and methodology reported in prior research. For each assessment, the online and face-to-face (FTF) clinicians simultaneously completed a structured CSE. On session completion, the online clinician indicated level of agreement with two statements regarding the level of rapport and ability to competently assess the patient.

RESULTS

In each of the four groups, acceptable levels of agreement were observed between raters for the three primary outcomes (decisions regarding oral/nonoral intake and safe food and fluids) as well as over 90% of the CSE items. Clinicians agreed they could develop good rapport with the majority of patients in all groups. However, for a small but significant (p<0.5) proportion of patents in the severe dysphagic group, clinicians disagreed they were able to satisfactorily and competently assess to the best of their abilities using the telerehabilitation system.

CONCLUSIONS

Clinical decisions made during and as an outcome of the total CSE were found to be comparable to those made in the FTF environment regardless of dysphagia severity. Clinicians noted some difficulty assessing patients with greater complexity, which occurred in greater numbers in the group with severe dysphagia.

Evaluation of a Clinical Service Model for Dysphagia Assessment via Telerehabilitation

Emerging research supports the feasibility and viability of conducting clinical swallow examinations (CSE) for patients with dysphagia via telerehabilitation. However, minimal data has been reported to date regarding the implementation of such services within the clinical setting or the user perceptions of this type of clinical service. A mixed methods study design was employed to examine the outcomes of a weekly dysphagia assessment clinic conducted via telerehabilitation and examine issues relating to service delivery and user perceptions. Data was collected across a total of 100 patient assessments. Information relating to primary patient outcomes, session statistics, patient perceptions, and clinician perceptions was examined. Results revealed that session durations averaged 45 minutes, there was minimal technical difficulty experienced, and clinical decisions made regarding primary patient outcomes were comparable between the online and face to face clinicians. Patient satisfaction was high and clinicians felt that they developed good rapport, found the system easy to use, and were satisfied with the service in over 90% of the assessments conducted. Key factors relating to screening patient suitability, having good general organization, and skilled staff were identified as facilitators for the service. This trial has highlighted important issues for consideration when planning or implementing a telerehabilitation service for dysphagia management.

Assessing dysphagia via telerehabilitation: patient perceptions and satisfaction

To gain insight into factors which may influence future acceptance of dysphagia management via telerehabilitation, patients' perceptions were examined before and after a telerehabilitation assessment session. Forty adult patients with dysphagia (M =66 years, SD =16.25) completed pre- and post-session questionnaires which consisted of 14 matched questions worded to suit pre- and post-conditions. Questions explored comfort with the use of telerehabilitation, satisfaction with audio and video quality, benefits of telerehabilitation assessments and patients' preferred assessment modality. Questions were rated on a 5-point scale (1 = strongly disagree, 3 = unsure, 5 = strongly agree). Patients' comfort with assessment via telerehabilitation was high in over 80% of the group both pre- and post-assessment. Pre-assessment, patients were unsure what to expect with the auditory and visual aspects of the videoconference, however there were significant positive changes reported post-experience. In relation to perceived benefits of telerehabilitation services in general, most patients believed in the value of telerehabilitation and post-assessment this increased to 90-100% agreement. Although 92% felt they would be comfortable receiving services via telerehabilitation, 45% of patients indicated ultimate preference for a traditional face-to-face assessment. The data highlight that patients are interested in and willing to receive services via telerehabilitation; however, any concerns should be addressed pre-assessment.

An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia

We investigated whether an expert's consultation provided via telemedicine could improve the quality of care for patients with dysphagia. A trained clinician completed videofluoroscopic swallowing studies (VFSS) of 17 consecutive patients in a Greek hospital. The videofluoroscopic images were then stored on a website for independent review by an expert Speech and Language Pathologist in the US. An extra Rater evaluated 20% of all data for additional reliability testing. Eight diagnostic indicators of swallowing impairment and an overall subjective severity index were recorded for each study. Clinicians were also asked to choose from ten common treatment options for patients with dysphagia. There was good inter-rater agreement for most of the diagnostic indicators examined (ranging from 78% to 90%; kappa = 0.52-0.71) between all three Raters. Agreement on overall severity ratings was exact for more than half of the patients and within one-point on the 4-point scale for all other patients except one. However, the quality of care would have been substandard for more than half of the patients if teleconsultation had not been employed. In settings where a swallowing expert is not available and real-time telemedicine is not feasible, the use of asynchronous teleconsultation can produce better quality of care for patients with dysphagia.

A pilot trial of a speech pathology telehealth service for head and neck cancer patients

We explored the feasibility of providing access to specialist speech pathology services via telehealth for patients with head and neck cancer. A weekly telehealth clinic was conducted between the speech pathology departments of a tertiary hospital and a regional hospital in Queensland. Over a 5-month period, 50 telehealth sessions were conducted for 18 patients. There were 38 patient consultations, nine case discussions between clinicians and three clinical training sessions relating to the skills needed for specific client management (e.g. voice prosthesis selection). Eight sessions had multidisciplinary involvement. All cases were successfully managed via telehealth. All patients agreed that they were comfortable using telehealth and would be happy to use it again in future. Both clinicians agreed that they could competently assess patients using the telehealth system. There appeared to be financial benefits for the patient, because by receiving specialist intervention at a local facility their travel expenses were lower. There was also the opportunity for workforce training and development through online case discussion and clinical consultation.

The Use of Telepractice Technology To Provide Speech and Language Services to Persons Aging With Communication Disorders

Telepractice, providing speech and language services at a distance from clients, is becoming another tool clinicians can use to provide services. Relieving the burden of travel may help those aging with a communication disability to access beneficial services. I will present evidence from several studies using telepractice for assessment and treatment of communication disorders. Although researchers have published promising results, future researchers should determine which populations will receive the most benefit from telepractice.

A new era in speech-language pathology practice: innovation and diversification

A new era in speech-language pathology practice is pending, and one that impels us to innovate and diversify as we move forward into the 21(st) century. The impetus for this transformation will include the increasing cost and demand for healthcare services as the population ages, changes in Australian society, rapid developments in technology, and major advances in neuroscience. New models of service delivery will need to be considered in line with evidence-based treatment protocols, the concept of a continuum of care for chronic disorders, and the need to engage clients in self-management. Innovations in technology will provide the means by which these new models of service delivery might be achieved. The exponential increase in electronic therapy resources and devices will transform the therapeutic process and provide clinicians with engaging and flexible therapy options. Clinicians will be challenged by this paradigm shift in service delivery, and their long-held perceptions of their clients' capacity to respond to these changes. Other challenges will include the preparation of future speech-language pathologists, reimbursement for services, availability of appropriate technology, and widespread connectivity. The future of the profession is an exciting one as we move forward into an era of unprecedented change.

Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future

This article provides a review of the evidence base for telepractice in speech-language pathology, the challenges that exist, and the future directions for this field. It describes the benefits of telepractice for clients and their families and outlines the evidence currently available to support the validity and reliability of this mode of delivery in the management of adult neurogenic communication disorders (aphasia, dysarthria, apraxia of speech); voice disorders; stuttering; dysphagia; laryngectomy; and articulation, language, and literacy disorders in children. The challenges facing telepractice in speech-language pathology and the future directions for this field are discussed.

Telepractice is an emerging area of service delivery in speech-language pathology that is likely to become an integral part of mainstream practice in the future. In order to achieve this, it is imperative that the profession accelerates its program of research and clinical endeavor in this area.

Assessing swallowing disorders online: a pilot telerehabilitation study

OBJECTIVE

Dysphagia (a swallowing disorder) is known to occur in numerous clinical populations, but unfortunately because of issues accessing speech pathology services, not all patients are able to receive dysphagia intervention and rehabilitation services in a timely manner. Existing research supports the use of telehealth technology for providing various aspects of speech pathology service; however, to date there is limited evidence to support the utilization of telerehabilitation in the assessment and management of dysphagia. The aim of this research was to provide pilot information on the basic feasibility and validity of conducting dysphagia assessments via telerehabilitation.

MATERIALS AND METHODS

Ten simulated patients, actors portraying patients with a range of swallowing difficulties, were used rather than actual patients to minimize any potential patient risk from unidentified aspiration. Dysphagia was assessed simultaneously by a face-to-face (FTF) and telerehabilitation speech pathologist (T-SP). Each simulated patient was assessed using a Clinical Swallowing Examination (CSE) protocol that was modified to suit a telerehabilitation environment. The CSE was administered with the support of an assistant via an Internet-based videoconferencing telerehabilitation system using a bandwidth of 128 kilobits per second.

RESULTS

Results revealed high to excellent levels of agreement between the T-SP and the FTF-SP across all parameters of the CSE. Agreement for aspiration risk was excellent.

CONCLUSION

The pilot data indicate that the current model of administering a CSE via telerehabilitation has potential to be a feasible and valid method for the remote assessment of swallowing disorders.

Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: an embedded study in a randomized trial

OBJECTIVE

We measured the satisfaction of both patients and healthcare professionals with the technologies and services provided during in-home telerehabilitation as an alternative to conventional rehabilitation after discharge from total knee arthroplasty surgery.

METHODS

This study was embedded in a larger controlled trial where 48 community-living older adults who received total knee arthroplasty were recruited prior to discharge from acute care following surgery and randomly assigned to treatment arms (Tele and Comparison). The participants' satisfaction with the services was assessed at the end of the intervention for both groups using the Healthcare Satisfaction Questionnaire. For the Tele group, the patients' perception of in-home telehealth was assessed before treatment and after completion of teletreatments. The satisfaction of the healthcare professionals with the technology during the telerehabilitation services was noted at the end of each treatment session using a technical quality subjective appreciation questionnaire.

RESULTS

Both groups of patients (Tele and Comparison) were satisfied with the services received and no significant difference was observed between them. Moreover, the physiotherapists' satisfaction with regard to goal achievement, patient-therapist relationship, overall session satisfaction, and quality and performance of the technological platform was high.

CONCLUSIONS

As patient satisfaction is important in maintaining motivation and treatment compliance and the satisfaction of healthcare professionals must be high in order for new treatments to become mainstream in clinics, the results show that in-home telerehabilitation seems to be a promising alternative to traditional face-to-face treatments.

The use of email as a component of adult stammering therapy: a preliminary report

In West Glasgow email has evolved from a rapid means of arranging therapy appointments with adults who stammer into a medium for exchange of therapeutic messages with some clients. Since 2004, sixteen clients have used email to communicate as part of their therapy programme. The benefits include improving access to services, supporting speech change, facilitating lasting personal growth, improving clinical decision-making, equalizing the therapist-client relationship and enhancing caseload management. Although this experience suggests that email is appropriate for stammering therapy, the effectiveness and ethics of, and the rationale for, clinical practice that includes email need careful consideration. Further research is required to formally evaluate the client experience.