Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond

Narrowing the Digital Divide: Framework for Creating Telehealth Equity Dashboards

Telehealth presents both the potential to improve access to care and to widen the digital divide contributing to health care disparities and obliging health care systems to standardize approaches to measure and display telehealth disparities. Based on a literature review and the operational experience of clinicians, informaticists, and researchers in the Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT)-Clinical and Translational Science Awards (CTSA) Network, we outline a strategic framework for health systems to develop and optimally use a telehealth equity dashboard through a 3-phased approach of (1) defining data sources and key equity-related metrics of interest; (2) designing a dynamic and user-friendly dashboard; and (3) deploying the dashboard to maximize engagement among clinical staff, investigators, and administrators.

Perceptions of Telehealth Services Among Rural Lung Cancer Patients in China: A Qualitative Study Using the Technology Acceptance Model

OBJECTIVES

To describe the perceptions of telehealth services among lung cancer patients in rural areas of China, as well as to explore the potential of telemedicine to improve long-term health recovery at home for rural lung cancer patients.

METHODS

A qualitative descriptive study design was used in this study and we conducted semi-structured interviews with 14 rural Chinese lung cancer patients between December 2022 and March 2023. Interview content was analyzed using Nvivo software and a framework analysis was performed using the Technology Acceptance Model to identify meaningful themes.

RESULTS

Participants identified perceptual and technical factors related to perceived ease of use, benefits and drawbacks related to perceived usefulness, and facilitators and barriers related to intention to use. However, regional and disease features including literacy barriers, medical insurance condition, symptom burden, and rural cultural health seeking behavior conduct must be taken into account.

CONCLUSIONS

Lung cancer patients in rural China believe that telehealth services could be an alternative solution for addressing health and care needs, but various aspects, such as user interface design, cost-effectiveness, and technological anxiety, need to be optimized.

IMPLICATIONS FOR NURSING PRACTICE

More highly specialized nursing team, friendly telecare lung function modules, and media technology training courses should be developed for rural lung cancer patients to enhance the quality of their home care, meet their information needs and better control their disease progression.

Mind-Body Interventions for Youth with Chronic Medical Conditions: A Scoping Review of the Literature

Background and purpose: Little is known about the applicability, utilization, and effectiveness of mind-body interventions (MBIs) for conditions that are not predominantly pain, neoplastic, or psychiatric, particularly in pediatric patients. This scoping review describes research pertaining to such interventions in youth with nonpain, noncancer, and nonpsychiatric predominant chronic medical conditions. Methods: Searches of EBSCO CINAHL, Elsevier Scopus, Ovid for MEDLINE, and Ovid PsycInfo were conducted to investigate MBIs in youth under 18 years of age with nonpain, noncancer, and nonpsychiatric predominant chronic medical conditions. Articles published between 2010 and 2020 were included. Abstracts were screened by three authors for inclusion, and disagreements were resolved by a designated author. Selected full-text articles were divided among all authors for review of study quality, intervention feasibility and acceptability, and effectiveness. Results: The search yielded 1010 titles with 15 meeting the final inclusion criteria, studying a total of 641 youth. Participants ranged in age from 6 to 19 years (included studies had data on participants <18 years reported separately); 61.5% were female (n = 394) and 38.5% were male (n = 247). The two most common conditions studied were asthma and irritable bowel syndrome, with yoga being the most popular intervention. Overall, MBIs showed promising preliminary evidence for improving symptoms and quality of life in youth with chronic medical conditions. Conclusion: MBIs have been successfully delivered and show promise in symptom palliation and quality of life improvement for youth with a variety of chronic medical conditions. More data from high-quality randomized controlled trials are needed to further characterize the effectiveness of specific modalities for specific conditions.

Advances in Pediatric Telehealth Education and Training: A National Survey

Background: The COVID-19 pandemic accelerated the formal integration of telehealth into education curricula and training programs, prompting the need to reevaluate the current landscape and inform a research agenda. We developed a survey to assess telehealth education and training curriculum, competencies, certification, and research across pediatric medical centers. Methods: Questions were derived from a previously published national survey and de novo. The survey was distributed across national pediatric professional associations. Results: In total, 32 respondents representing medical centers (86.5%) were providing telehealth education and/or training. Most were internally developed didactic (78.6%) and experiential (64.3%) curricula. Respondents who included education and/or training in telehealth research protocols and conducted telehealth research (74%) reported mandatory or optional training in tele-research. A form of certification was preferred by most organizations (>60%). Conclusion: Telehealth education and training are key factors within current and future service development, provision, and research to demonstrate competencies and positively impact patient care.

Clinical practice guidelines for the care of girls and women with Turner syndrome

Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.

Multicenter study assessing physicians' and transport teams' attitudes and expectations about utilizing telemedicine to manage critical neonatal transports

BACKGROUND

Managing critically ill neonates has unique challenges, and the transport team plays an important role in stabilizing and facilitating the transfer of these neonates from lower-level nurseries to tertiary centers, and the use of telemedicine in transport (tele-transport) can potentially benefit patient care. We conducted a multicenter study to assess the readiness for utilizing telemedicine as an adjunct to guide the care of critically ill neonates among physicians and transport team members (TTMs). This is the first multicenter study that explored physicians' and TTMs' perceptions of telemedicine usage and its value in neonatal transport.

METHODS

A confidential, voluntary survey on pre-implementation attitudes toward telemedicine usage during neonatal transport was conducted as part of a quality improvement initiative. This survey involved physicians and TTMs from four academic institutions whose responses were entered into an online survey using REDCap®. The survey inquired about satisfaction with the current practice of phone consultation and the perception of using telemedicine to optimize the management of neonates during transport.

RESULTS

The overall response rate for the survey was 60.1%; 82 of 127 (64.6%) physicians and 64 of 116 (55.2%) TTMs responded to the surveys. Half of the physicians and less than one-fourth of the TTMs had prior experience with telemedicine other than that used on neonatal transport. TTMs expressed greater concern about the inconvenience of video (55% vs. physicians 35% agree or strongly agree) and its time consumption (84% vs. physicians 50%). More than 70% of physicians and less than half of TTMs endorsed the potential for added value and quality improvement with video capability. Almost half of TTMs reported concern about video calls reducing their autonomy in patient care. Physicians expressed confidence in management decisions they would make after video calls (72% confident or very confident) and less confidence (49%) about both the phone assessment by TTMs and their decisions based on phone assessment. In contrast, TTMs were confident or very confident (94%) in both sharing their assessment over the phone and executing patient management after a phone call, compared with 70% for decisions made after video calls.

CONCLUSIONS

Physicians and TTMs had distinct opinions on the use of telemedicine during neonatal transport. Physicians were more likely than TTMs to agree with statements about the potential for improving quality of care, while TTMs were more likely than physicians to say video calls would be time-consuming and inconvenient. We speculate some differences may stem from the TTMs' concern about losing their autonomy. Therefore, during implementation, it is critical for physicians and TTMs to agree on a shared mental model of indications for telemedicine during transport and its value to the patient care.

Quality of Outpatient Pediatric Palliative Care Telehealth: A Retrospective Chart Review

CONTEXT

Studies suggest the feasibility and acceptability of telehealth in outpatient pediatric palliative care. However, there is a need for data that describes the implementation and quality of telehealth, relying on objective and validated measures.

OBJECTIVE

We sought to compare the provision of pediatric palliative care by delivery method.

METHODS

We conducted a retrospective electronic health record review of patients seen by our outpatient palliative care team over a two-year period. Demographic, diagnostic, and health utilization data as well as encounter characteristics were compared between patients seen in person (IP), through telehealth (TH), and both (IP/TH).

RESULTS

Three hundred ninety-four patients were evaluated with 889 outpatient pediatric palliative care encounters. Non-English speaking patients were less likely to receive palliative care through TH, as were patients without active patient portals. Median follow-up time was longer for patients seen through TH or IP/TH. Patients with malignancies were seen more frequently IP while children with neurologic diagnoses, technology dependence, and a higher number of complex chronic conditions were seen more frequently via TH. Health outcomes, end of life quality metrics, and encounter-level quality indicators were similar across care delivery methods. Review of systems, pain, and mood management, and advance care planning happened more frequently IP while goals of care discussions and medical decision-making happened more through TH.

CONCLUSION

Despite differences in patients seen and palliative interventions provided in person compared to telehealth, health outcomes, and quality indicators were similar across care delivery methods. These data support the continued practice of telehealth in palliative care and highlight the need for equity in its evolution.

Utilization and Patient-Reported Outcomes of Direct-to-Consumer Telemedicine During the First 6 Weeks of the COVID-19 Pandemic in the Largest Pediatric Ambulatory Network in New York State

Objective: We aimed to (1) describe telemedicine utilization and usability during the first 6 weeks of the pandemic and (2) determine if usability varied by individual- or visit-level characteristics. Methods: We conducted a retrospective cohort study of ambulatory pediatric telemedicine visits occurring between March 10, 2020, and April 18, 2020, across a large academic health system. We performed manual chart review to assess individual- and visit-level characteristics and invited caregivers to respond to an adapted Telehealth Usability Questionnaire (TUQ). We used multiple logistic regression to determine predictors of high usability. Results: There were 3,197 ambulatory pediatric telemedicine visits, representing 2,967 unique patients. Patients were racially/ethnically diverse (42.5% non-Hispanic White) and primarily English-speaking (89.2%). Surveys were completed by 441 (17%) of those invited. Every item of the TUQ had agreement or strong agreement from the majority of respondents. Compared with non-Hispanic White, non-Hispanic Asian identity was associated with lower usability in three domains and overall, and non-Hispanic Black identity was associated with higher satisfaction and future use. As compared with caregivers of infants younger than 1 year, caregivers of older patients reported lower usability in the three domains. Conclusions: Telemedicine was successfully implemented across 18 ambulatory pediatric specialties in the largest health system in New York State at the onset of COVID-19, and caregivers found it usable and acceptable. Usability scores did not vary by visit-level characteristics but did vary by race/ethnicity and age. Further research is necessary to identify modifiable drivers of the patient experience, particularly in non-Hispanic Asian communities and older adolescents.

Healthcare visits for new neurodevelopmental problems before and during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted healthcare delivery. We hypothesized that children with neurodevelopmental problems would have reduced healthcare utilization during the pandemic compared to before the pandemic.

METHODS

We conducted a population-based study of healthcare visits for new neurodevelopmental problems among children ages 0-6 years in Ontario, Canada. Our outcome measure was rate per 1000 children-months for healthcare visits for new neurodevelopmental problems. We compared changes in monthly rates before and during the pandemic using interrupted time series analysis (ITSA).

RESULTS

The rate of new neurodevelopmental problems before the pandemic was 6.31 per 1000 children-months and during the pandemic was 6.58 per 1000 children-months. However, using ITSA, there were no differences in monthly rates of healthcare visits for new neurodevelopmental problems before and during the pandemic. The observed rate during the first 30 days of the pandemic dropped to 3.40 per 1000 children-months.

CONCLUSION

We found no significant difference in rates of healthcare visits for new neurodevelopmental problems before and during the pandemic. There was a decrease in the number of visits during the first 30 days of the pandemic compared to all months prior.

IMPACT

This study found no significant difference in rates of healthcare visits for new neurodevelopmental problems before and during the pandemic. There was a decrease in the number of visits during the first 30 days of the pandemic compared to all months prior. This study adds information on healthcare access for children during the COVID-19 pandemic. The rapid deployment of virtual healthcare delivery in Ontario, Canada may explain the fast recovery of healthcare utilization for children with neurodevelopmental problems.

Evaluation of the Safer Use of Antipsychotics in Youth Study on Population Level Antipsychotic Initiation: An Interrupted Time Series Analysis

Background: Antipsychotics carry a higher-risk profile than other psychotropic medications and may be prescribed for youth with conditions in which other first-line treatments are more appropriate. This study aimed to evaluate the population-level effect of the Safer Use of Antipsychotics in Youth (SUAY) trial, which aimed to reduce person-days of antipsychotic use among participants. Methods: We conducted an interrupted time series analysis using segmented regression to measure changes in prescribing trends of antipsychotic initiation rates pre-SUAY and post-SUAY trial at four U.S. health systems between 2013 and 2020. Results: In our overall model, adjusted for age and insurance type, antipsychotic initiation rates decreased by 0.73 (95% confidence interval [CI]: 0.30, 1.16, p = 0.002) prescriptions per 10,000 person-months before the SUAY trial. In the first quarter following the start of the trial, there was an immediate decrease in the rate of antipsychotic initiations of 6.57 (95% CI: 0.99, 12.15) prescriptions per 10,000 person-months. When comparing the posttrial period to the pretrial period, there was an increase of 1.09 (95% CI: 0.32, 1.85) prescriptions per 10,000 person-months, but the increasing rate in the posttrial period alone was not statistically significant (0.36 prescriptions per 10,000 person-months, 95% CI: -0.27, 0.99). Conclusion: The declining trend of antipsychotic initiation seen between 2013 and 2018 (pre-SUAY trial) may have naturally reached a level at which prescribing was clinically warranted and appropriate, resulting in a floor effect. The COVID-19 pandemic, which began in the final three quarters of the posttrial period, may also be related to increased antipsychotic medication initiation.

Advancing Pediatric Care: The virtualKIDS Experience in Nursing-Led Audio-Visual Clinical Services

During the COVID-19 pandemic, the escalating trend of pediatric patients, particularly non-urgent cases, going to the emergency departments (EDs) in New South Wales, Australia, prompted the establishment of virtualKIDS, a nursing-led telehealth service. This service, initiated in June 2021, operates 24/7 and provides comprehensive care through audio-visual consultations emphasizing a patient-centered approach. Three elements-COVID-19 Outpatient Response Team (CORT), virtualKIDS Acute Review (vKAR), and Virtual Urgent Care (VUC)-addressed specific needs during and beyond the pandemic, showcasing the adaptability and impact of virtual care. vKAR focuses on post-discharge support, allowing families access to telehealth for up to three days. Preliminary data indicates a 44% reduction in ED visits within 48 h. VUC employs nursing-led triaging paired with audiovisual assessment, demonstrating a 69% hospitalization avoidance rate. Hybrid ambulatory models such as a sleep study at home project, day-only tonsillectomies, and arthroscopic knee surgeries showcase innovative approaches to reducing hospital admissions and enhancing patient outcomes. This paper presents the evolution and diverse models of care implemented by the virtualKIDS service, offering insights into its potential as a nursing-led alternative to ED visits in acute-care pediatrics.

A Systematic Review of Telehealth-Based Pediatric Cancer Rehabilitation Interventions on Disability

Background: Telehealth is an emerging method which may overcome barriers to rehabilitation access for pediatric cancer survivors (aged ≤19 years). This systematic review aimed to examine telehealth-based rehabilitation interventions aimed at preventing, maintaining, or improving disability in pediatric cancer survivors. Methods: We performed systematic searches in Ovid MEDLINE, Ovid EMBASE, Cochrane Library, SCOPUS, Web of Science, and CINAHL Plus between 1994 and 2022. Eligible studies included telehealth-based interventions assessing disability outcomes in pediatric cancers. Results: Database searches identified 4,040 records. Nine unique interventions met the eligibility criteria. Telehealth delivery methods included telephone (n = 6), email (n = 3), mobile health applications (n = 3), social media (n = 3), videoconferencing (n = 2), text messaging (n = 2), active video gaming (n = 2), and websites (n = 2). Interventions focused on physical activity (n = 8) or self-management (n = 1). Outcomes assessing disability varied (n = 6). Three studies reported statistically and clinically significant results. Narrative synthesis of findings was constructed based on the Picker's principles for patient-centered care: (1) values, preferences, and needs; (2) involve family and friends; (3) coordination of care; (4) provide social support; (5) holistic well-being; and (6) information and communication. Conclusions: Telehealth-based rehabilitation interventions for pediatric cancer survivors is an emerging research area with potential to improve disability outcomes. Adequately powered trials with consistency in disability outcome measures are warranted. Additional research is needed to determine the effectiveness and best practices for telehealth-based pediatric cancer rehabilitation.

Has telemedicine come to fruition? Parents' and pediatricians' perceptions and preferences regarding telemedicine

BACKGROUND

Telemedicine has increasingly become a viable option for patient care and may increase access to care. The aim of our study was to evaluate both parent and pediatrician perceptions, preferences, and acceptability regarding the use of different telemedicine modalities.

METHODS

We conducted a cross-sectional survey of both parents and pediatricians in Geneva, Switzerland in 2021. The questionnaire focused on digital literacy, preferences, acceptability, advantages, and disadvantages regarding telemedicine (phone, email, video, and instant message). Descriptive statistics and comparisons of preferences and perceptions (Pearson Chi2 and logistic regression) were performed.

RESULTS

Two hundred and twenty-two parents and 45 pediatricians participated. After face-to-face consultations, parents and pediatricians preferred the phone for simple medical advice, discussion of parameters, acute or chronic problems, and psychological support. Email was preferred for communication of results and prescription renewal. Main reasons for using telemedicine were avoiding travel and saving time. Disadvantages were lack of physical examination, technical problems, and unsuitability of the reason for consultation.

CONCLUSIONS

Understanding the factors that influence acceptance and satisfaction with telemedicine is vital for its successful implementation. Convenience, quality of care, trust, strong pediatrician-parent relationships, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping parent and pediatrician attitudes toward telemedicine.

IMPACT

The COVID-19 pandemic spurred the expansion of the use of telemedicine in pediatric care. Few studies have addressed parent and pediatrician perceptions and preferences regarding telemedicine. Both parents and pediatricians consider certain telemedicine modalities (phone, email, video, and instant message) pertinent in only specific clinical situations. Advantages of telemedicine outweigh disadvantages with parents and pediatricians appreciating the increased access to care, time savings, and avoiding transport. However, the lack of a physical examination remains a significant disadvantage. Convenience, quality of care, trust, strong pediatrician-parent relationship, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping attitudes towards telemedicine.

Impact of COVID-19 on the Pediatric Primary Care Model in Catalonia: Analysis of Changes in the Number and Type of Face-to-Face and Remote Visits

Background

The outbreak of COVID-19 has turned the care model of health systems around the world upside down. The health care crisis has led to opportunities for digital health to deliver quality care, and the system has been redirected toward telemedicine. In Catalonia, Spain, as of March 2020, the pattern of visits in primary care pediatric consultations changed, such that face-to-face visits decreased in favor of non-face-to-face visits.

Objective

This study aimed to analyze variations in the types of pediatric visits in primary care centers in Catalonia before and after the onset of COVID-19.

Methods

This was a descriptive observational study based on administrative data. The number and type of visits to primary care pediatric services in Catalonia between January 2019 and December 2022 were studied.

Results

A drop of more than 80% in face-to-face visits and an increase of up to 15 times in remote visits were observed as of March 2020 compared to the previous year. Subsequently, the face-to-face attendance rate began to recover, although it did not reach the same rate as before COVID-19. Non-face-to-face visits were maintained, representing more than 20% of the total after more than 2 years of the pandemic.

Conclusions

COVID-19 has been the trigger for a transition in the types of visits to primary care pediatric services. The COVID-19 pandemic was a clear catalyst for the integration of telemedicine in Catalan pediatric health care. In this context, although face-to-face consultations have recovered in absolute numbers, after the pandemic period, the weight of telemedicine has increased.

Telehealth and Children with Medical Complexity

Although use of telehealth may have begun centuries ago and has grown considerably through the 20th century, the coronavirus disease 2019 pandemic skyrocketed telemedicine's reach, including its use in pediatrics. The American Academy of Pediatrics endorses telehealth as a "critical infrastructure to efficiently implement the medical home model of care." Particularly for children with medical complexity (CMC), telehealth offers great promise to improve access to continuous, coordinated primary care, reduce time to pediatric subspecialty care, and support distance education for both pediatric providers and patients and their families. This article details the numerous benefits of telehealth to CMC with an emphasis on its use as an extender of the medical home, describes the venues in which telehealth augments access to safe, high-quality care, presents best practices in engaging in telehealth encounters, and enumerates barriers that may exacerbate current health inequities. We review current published telehealth patient-/caregiver-level, clinician-level, and payor-level outcomes while revealing research gaps and opportunities. [Pediatr Ann. 2024;53(3):e74-e81.].

Interprofessional online course for telehealth delivery of pediatric developmental services

PURPOSE

This study aimed to examine the effectiveness of an interprofessional telehealth course developed based on a collaborative needs assessment of professionals working in community-based child-development units.

MATERIALS AND METHODS

Ninety-six pediatric therapists, including psychologists, social workers, speech-language pathologists, physiotherapists, and occupational therapists, participated in a 10-week, 30-hour online training on best practices in telehealth delivered according to adult learning theory guidelines. Participants reported their telehealth competencies before and after the training using a questionnaire developed for the study.

RESULTS

Repeated paired t-tests showed significant increases with high effect sizes in participants' knowledge, attitudes, emotions, and willingness to use telehealth in their practices. However, at follow-up, the implementation rates remained low.

CONCLUSIONS

Online learning tailored to learners' needs can change knowledge, attitudes, and willingness to incorporate telehealth into routine care. Collaboration among regulators, foundations, professional associations, and clients attuned to health care's changing needs is essential to providing solutions and boosting the quality of rehabilitation services. However, providing knowledge alone is not enough: Sustainable implementation planning is essential for knowledge translation.IMPLICATIONS FOR REHABILITATIONTelehealth can enhance access to rehabilitation services, but providers require training to promote knowledge, attitudes, and willingness to incorporate telehealth into routine care.Effective training should be based on collaboration among all stakeholders, from needs assessment and content development to implementation and devising a plan to translate sustainable knowledge into rehabilitation.Training courses should combine content on best practices with a delivery approach based on adult learning principles.To translate knowledge into practice, the course must be a part of a sustainable implementation plan at the workplace.

What's after COVID-19?: Communication pathways influencing future use of telehealth

OBJECTIVE

Telehealth usage for healthcare encounters has increased dramatically due to the coronavirus disease (COVID-19) precautions. As the pandemic health threat subsides, it is important to understand how telehealth encounters are perceived by users. In this study, we explore how patient-centered communication (PCC), and media and organizational factors, influence patients' intentions to use telehealth in the future.

METHODS

An online survey was conducted among 326 adult patients who reported visiting a healthcare provider using telehealth within the past 12 months. Structural equation modeling explored how contextual factors influenced patients' adoption of telehealth.

RESULTS

PCC and ease of use indirectly predicted telehealth adoption through enhanced patient satisfaction and sense of care continuity. Sense of security indirectly predicted telehealth adoption via its association with enhanced rating of care quality.

CONCLUSION

The functionality of telehealth technology does not solely determine patients' telehealth adoption. Instead, positive healthcare experiences, facilitated by organizational support, quality media designs, as well as patient-centered communication, are associated with telehealth adoption.

PRACTICE IMPLICATIONS

Healthcare providers should strategically improve telehealth-related communication processes that can lead to better patient health outcomes.

Feasibility, Acceptability, and Health Outcomes Associated With Telehealth for Children in Families With Limited English Proficiency

BACKGROUND

Telehealth use in pediatrics increased during the COVID-19 pandemic and may improve health care access. It may also exacerbate health care disparities among families with limited English proficiency (LEP).

OBJECTIVE

To systematically review the feasibility, acceptability, and/or associations between telehealth delivery and health outcomes for interventions delivered synchronously in the United States.

DATA SOURCES

PubMed, Embase, and Scopus.

STUDY ELIGIBILITY CRITERIA

Original research exploring pediatric health outcomes after telehealth delivery and studies that explored the feasibility and acceptability including surveys and qualitative studies.

PARTICIPANTS

Patients 0 to 18 years with LEP and/or pediatric caregivers with LEP.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened abstracts, conducted full-text review, extracted information using a standardized form, and assessed study quality. A third author resolved disagreements.

RESULTS

Of 1831 articles identified, 9 were included in the review. Half of the studies explored videoconferencing and the other half studied health care delivered by telephone. Feasibility studies explored telehealth for children with anxiety disorders and mobile phone support for substance abuse treatment among adolescents. Acceptability studies assessed parental medical advice-seeking behaviors and caregivers' general interest in telehealth. Health outcomes studied included follow-up of home parenteral nutrition, developmental screening, and cognitive behavioral therapy.

LIMITATIONS

The articles were heterogeneous in approach and quality.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Telehealth appears acceptable and feasible among children in families with LEP, with a limited evidence base for specific health outcomes. We provide recommendations both for the implementation of pediatric telehealth and future research.

PROSPERO REGISTRATION

CRD42020204541.

School-Based Telemedicine and Reduced Avoidable Emergency Care Among Rural Pediatric Patients

Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.

Parents' Preferences for Primary Care-Based Behavioral Services and the COVID-19 Pandemic: A Mixed Method Study

OBJECTIVE

This study examined how family factors impacted parents' attitudes toward integrated behavioral health (IBH) in pediatric primary care during the COVID-19 pandemic. We hypothesized that COVID-19 impact would predict family functioning challenges, and that pre-existing familial contextual factors would predict parents' interest in IBH modalities.

METHODS

Parents of children ages 1.5-5 years (N = 301) from five primary care clinics completed a survey with measures assessing familial contextual factors (income, race and ethnicity, and parents' childhood adversity), COVID-19 impact on family relationships and wellbeing, family functioning (child behavior, parenting self-efficacy, and parent psychological functioning), and parents' preferences for behavioral support in primary care. A subsample of parents (n = 23) completed qualitative interviews to provide deeper insights into quantitative relationships.

RESULTS

Higher COVID-19 impact was significantly associated with worse parent mental health and child behavior problems, as well as lower interest in IBH virtual support options. Overall, lower SES and racial and/or ethnic minority parents both indicated greater interest in IBH modalities compared to higher SES and White parents, respectively. Qualitative interviews identified how pandemic stressors led to increases in parents' desire for behavioral support from pediatricians, with parents sharing perspectives on the nature of support they desired, including proactive communication from providers and variety and flexibility in the behavioral supports offered.

CONCLUSIONS

Findings have important implications for the provision of behavioral supports for families in primary care, underlying the need to increase parents' access to IBH services by proactively providing evidence-based resources and continuing to offer telehealth support.

Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs

OBJECTIVE

In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care.

METHODS

This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care.

RESULTS

Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours.

CONCLUSIONS

Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.

Comparing the suitability of virtual versus in-person care: Perceptions from pediatricians

OBJECTIVES

The COVID-19 pandemic compelled a portion of healthcare to be delivered virtually. As the pandemic waned, health systems strived to find a balance between re-incorporating in-person care while maintaining virtual care. To find when virtual or in-person encounters are more appropriate, we surveyed pediatricians' perceptions when comparing the suitability of virtual care to in-person care.

METHODS

We surveyed a Canadian tertiary-level pediatric hospital where pediatricians assessed whether specific clinical encounters or tasks were more or less effective virtually than when performed in person. Pediatricians also rated the importance of clinical and patient factors when deciding if a patient needs to be seen in person.

RESULTS

Of 160 pediatrics faculty members, 56 (35%) responded to the survey. When assessing different types of clinical encounters, triage, multidisciplinary meetings, discharge, and follow ups were more likely to favor virtual encounters. However, first consultations and family meetings were more likely to favor in-person encounters. Regarding clinical tasks, pediatricians were more likely to endorse explaining test results, offering treatment recommendations, and obtaining patient histories virtually. On the contrary, there was a preference for physical examinations, assessing patients visually, and assessing developmental milestones to be performed in person. When deciding if a patient should be seen in person versus virtual, pediatricians rated the patient's condition and communication barriers as the most important factors favoring an in-person appointment.

DISCUSSION

These results offer an initial framework for pediatricians when choosing which encounter type may be most appropriate for their patients between virtual or in-person appointments.

Trends in Pediatric Primary Care Visits During the COVID-19 Pandemic: Opportunity to Address Adolescent Behavioral Health Through Telemedicine

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic impacted the volume and nature of pediatric primary care visits nationwide. This study aimed to identify trends in pediatric visits at our institution during the pandemic to reveal opportunities to improve care of children and adolescents.

METHODS

We performed a retrospective chart review of all pediatric visits conducted at a single family medicine clinic within a large academic medical center in Northern California from January 1, 2019, through September 30, 2021. Data collected for each visit included age, sex, type of visit (preventive or problem-focused), reason for visit (if problem-focused), and mode of visit (in-person or telehealth). We analyzed data using descriptive statistics and χ2 tests.

RESULTS

A total of 4,844 pediatric visits occurred during the study period. Visit volume dropped 9% from 2019 to 2020 and recovered to prepandemic levels in 2021. During the study period from 2019 to 2021, the percentage of problem-focused visits increased from 30% to 37% (P=.008) among adolescents, driven largely by an increase in the percentage of behavioral health visits from 14% to 29% (P<.001). We found no significant changes in the age or sex of patients seen. Telemedicine visit volume decreased from 2020 to 2021 in all age categories except for adolescents, which remained stable at 43% of all visits.

CONCLUSIONS

A sharp increase in behavioral health concerns among adolescents stands out as the most notable impact of COVID-19 on pediatric care at our institution. Our findings raise questions about how behavioral health care can be optimized for adolescents in the postpandemic era.

Fulfilling 6 Domains of Health Care Quality: A Qualitative Parental Caregiver Study of Pediatric Telehealth During a Pandemic

Using qualitative methods, we examine telehealth care quality from the perspective of parents of pediatric patients during a pandemic. We fill a gap in the literature essential for measuring effectiveness of pediatric telehealth. A total of 22 participants (n = 21 female; n = 1 male) enrolled in 1 of 9 interviews and focus groups conducted in 2021. Transcribed data were thematically analyzed and organized based on the 6 domains of quality health care by the Institute of Medicine (IOM). Analyzed data revealed 7 themes and 52 codes. Pediatric telehealth visits were perceived as efficient, timely, safe, and generally effective by parents for their child's health care. Participants experienced equal or greater time with their child's care provider via telehealth than through in-person visits. Qualitative results directly align with IOM domains of quality health care and contribute to the growing literature and evidence that may lead to improved telehealth outcomes and better preparedness for emergent public health events.

Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial

BACKGROUND

Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period.

OBJECTIVE

We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes.

DESIGNS, SETTINGS, AND PARTICIPANTS

We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care.

INTERVENTION

We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families.

MAIN OUTCOME AND MEASURES

Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time.

RESULTS

This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.

Prioritizing educational initiatives on emerging technologies for Italian pediatricians: bibliometric review and a survey

BACKGROUND

Emerging technologies have demonstrated outstanding potential in improving healthcare, yet their full integration remains a challenge for all medical specialties, including pediatrics. To support the swift implementation of technologies, we identified the current trends through a bibliometric review, and we conducted a survey on Italian pediatricians to gauge educational needs and willingness to integrate technologies into clinical practice.

METHODS

A working group of pediatricians representing various backgrounds designed and coordinated the study. To identify relevant topics for educational strategy development, we focused on virtual reality, telehealth, natural language processing, smartphone applications, robotics, genomics, and artificial intelligence. A bibliometric analysis limited to 2018-2023 was performed to identify trends and emerging applications within each topic. Based on the results, a questionnaire was developed and made available online to all Italian pediatricians. The results were analyzed through descriptive analysis and a multivariable logistic regression to explore associations between technology adoption and sociodemographic characteristics.

RESULTS

A total of 3,253 publications were found, with Telehealth and Telemedicine having the highest number of publications and Natural Language Processing the lowest. The number of respondents to the online questionnaire was 1,540, predominantly medical doctors with over 20 years of experience working as family pediatricians. Telehealth had the highest level of knowledge (95.2%), followed by smartphone applications (89.1%) and genomics (63.2%). The greatest potential for increased use through education programs was projected for natural language processing (+ 43.1%), artificial intelligence (+ 39.6%), and virtual and mixed reality (+ 38.1%). Female respondents and older individuals were less likely to use emerging technologies. Hospital pediatricians and residents were more likely to use AI.

CONCLUSIONS

We developed a replicable strategy to identify emerging themes in medical technologies relevant to pediatrics and assess the educational needs of pediatricians. A significant gap still exists between current and potential usage of emerging technologies among Italian pediatricians although they showed a positive attitude towards implementing these technologies following specific education programs. The study highlights the need for comprehensive education programs on emerging technologies in pediatrics and recommends addressing gender and age disparities in technology adoption.

Pediatric, Urgent Care Telemedicine During COVID-19: A Comparative Analysis

Background: Telemedicine holds potential for improving access to care, but to what extent has it been realized? We examined telemedicine utilization within a pediatric health care system into the second year of the COVID-19 pandemic to illuminate maintenance of changes in patient diversity previously observed and to elucidate ongoing opportunities to support health equity. Materials and Methods: This IRB-approved study is a retrospective analysis of completed visits for parent-initiated, urgent care telemedicine services received by a pediatric health care system between June 2020 and July 2021. Unique patient characteristics were compared with those from 2019 (baseline) and early pandemic. Results: Current study patients (n = 9,064) did not differ from patients in either prior time point (n = 5,462) in race, ethnicity, age, or sex (ps > 0.05). Thirteen preferred languages spoken, relative to 5 at the 2019 baseline. Telemedicine was utilized significantly more than baseline among patients accessing government-subsidized health insurance (p < 0.05); utilization among rural patients (1.2%) declined relative to baseline (p < 0.05). Discussion: This research examined demographic changes among patients utilizing urgent care telemedicine throughout the COVID-19 pandemic and illuminated the importance of sustaining the virtual care needs of a more diverse patient population. Conclusion: Unlocking telemedicine's potential has implications for improving health equity. Our research demonstrates that patients seeking virtual care in the "new normal" represent a greater demographic diversity than observed prepandemic. Mitigation strategies used during the pandemic to engage and support a diverse patient population, including regulatory waivers, technological outreach, and translation services, must continue in support of equitable access for all.

Pediatric Telehealth Access and Utilization in Chicago During the First Year of the COVID-19 Pandemic

Background: The COVID-19 pandemic demanded rapid development of telemedicine services for pediatric care and highlighted disparities for marginalized communities. Objective: To understand the demographic characteristics of patients with completed and incomplete telemedicine visits at Ann and Robert H. Lurie Children's Hospital of Chicago. Methods: This was a cross-sectional retrospective analysis of telemedicine visits for patients <25 years old scheduled between March 21, 2020, and March 17, 2021. We examined visit outcomes and compared outcomes by race/ethnicity, language, and payer using logistic regression. Geographic information system mapping and linear regression were used to examine the relationship between incomplete visits and broadband access within Cook County. Results: A total of 13,655 eligible video visits were scheduled for children within 147 ZIP codes during the study time frame. Patient characteristics included median age 9 years, 53% female, 42% non-Latinx White, 31% Latinx, 13% non-Latinx Black, 11% non-Latinx other, and 3% declined/unknown. Preferred language was 89% English, 10% Spanish, and 1% other. Payer was 56% private, 43% public, and <1% other/self-pay. Overall, 86% video visits were completed, 7% cancelled, and 7% no-show with significant variation by patient demographic. Odds of incomplete visits were higher for Latinx patients (odds ratio [OR] 1.93) and non-Latinx Black patients (OR 2.33) than for non-Latinx White patients, patients with preferred language other than English (OR 1.53), and patients not privately insured (OR 1.89). Incomplete visit rates and broadband access were inversely related. Conclusion: System and policy solutions are needed to ensure equitable access and address disparities in incomplete telemedicine visits for marginalized populations in urban areas with lower broadband.

Evaluation Strategies for Understanding Experiences With Virtual Care in Canada: Mixed Methods Study

BACKGROUND

Virtual care was rapidly integrated into pediatric health services during the COVID-19 pandemic. While virtual care offers many benefits, it is necessary to better understand the experiences of those who receive, deliver, and coordinate virtual care in order to support sustainable, high-quality, and patient-centered health care. To date, methods implemented to evaluate users' experiences of virtual care have been highly variable, making comparison and data synthesis difficult.

OBJECTIVE

This study aims to describe evaluation strategies currently used to understand personal experiences with pediatric virtual care in Canada.

METHODS

In this mixed methods environmental scan, we first distributed a web-based questionnaire to clinical, research, and operational leaders delivering and evaluating pediatric virtual care in Canada. The questionnaire collected information about how experiences with virtual care have been or are currently being evaluated and whether these evaluations included the perspectives of children or youth, families, providers, or support staff. Second, respondents were asked to share the questions they used in their evaluations, and a content analysis was performed to identify common question categories. Third, we conducted semistructured interviews to further explore our respondents' evaluation experiences across 4 domains-evaluation approaches, distribution methods, response rates, and lessons learned-and interest in a core set of questions for future evaluations.

RESULTS

There were 72 respondents to the web-based questionnaire; among those who had conducted an evaluation, we identified 15 unique evaluations, and 14 of those provided a copy of the tools used to evaluate virtual care. These evaluations measured the virtual care experiences of parents or caregivers (n=15, 100%), children or youth (n=11, 73%), health care providers (n=11, 73%), and support staff (n=4, 27%). The most common data collection method used was electronic questionnaires distributed by email. Two respondents used validated tools; the remainder modified existing tools or developed new tools. Content analysis of the 14 submitted questionnaires revealed that the most common questions were about overall participant satisfaction, the comparison of virtual care to in-person care, and whether participants would choose virtual care options in the future. Interview findings indicate respondents frequently relied on methods used by peers and that a standardized, core set of questions to evaluate experiences with virtual care would be helpful to improve evaluation practices and support pediatric health care delivery.

CONCLUSIONS

At our institution and elsewhere in Canada, experiences with pediatric virtual care have been evaluated using a variety of methods. A more consistent evaluation approach using standardized tools may enable more regular comparisons of experiences with virtual care and the synthesis of findings across health care settings. In turn, this may better inform our approach to virtual care, improve its integration into health systems, and facilitate sustainable, high-quality, patient-centered care.

A pediatric virtual care evaluation framework and its evolution using consensus methods

BACKGROUND

The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care.

METHODS

We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program.

RESULTS

The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program.

CONCLUSIONS

This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study

PURPOSE

Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents' perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care.

METHODS

We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY.

RESULTS

Participants (n = 88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component.

DISCUSSION

Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth's preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.

Caregiver Perspectives on Telemedicine for Postdischarge Care for Children With Medical Complexity: A Qualitative Study

INTRODUCTION

The objectives of this study were to describe the perspectives of caregivers of children with medical complexity on telemedicine video visits (TMVV) for posthospitalization care and determine whether TMVV may be a viable alternative to in-person follow-up.

METHOD

Our qualitative descriptive study included semistructured telephone interviews with 12 caregivers. Data analysis was conducted using an adapted Colaizzi's descriptive phenomenological method for thematic construction.

RESULTS

Results were organized into four themes describing caregivers' experiences with TMVV: (1) promoted caregiver self-efficacy and sense of independence; (2) TMVV as convenient, cost-effective, comprehensive, and acceptable; (3) supported caregiver decision-making and problem-solving; and (4) fostered delivery of family-centered care.

DISCUSSION

Although in-person visits are necessary for some circumstances, TMVV can serve as a convenient and acceptable alternative for posthospitalization follow-up in children with medical complexity. Overall, caregivers in this study were satisfied with the quality of care and individualized experience of TMVV.

Telehealth utilization barriers among Alabama parents of pediatric patients during COVID-19 outbreak

BACKGROUND

Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs.

METHODS

This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above.

RESULTS

Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child.

CONCLUSIONS

This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions

Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.

A Conceptual Framework for Group Well-Child Care: A Tool to Guide Implementation, Evaluation, and Research

OBJECTIVE

To use scoping review methods to construct a conceptual framework based on current evidence of group well-child care to guide future practice and research.

METHODS

We conducted a scoping review using Arksey and O'Malley's (2005) six stages. We used constructs from the Consolidated Framework for Implementation Research and the quadruple aim of health care improvement to guide the construction of the conceptual framework.

RESULTS

The resulting conceptual framework is a synthesis of the key concepts of group well-child care, beginning with a call for a system redesign of well-child care to improve outcomes while acknowledging the theoretical antecedents structuring the rationale that supports the model. Inputs of group well-child care include health systems contexts; administration/logistics; clinical setting; group care clinic team; community/patient population; and curriculum development and training. The core components of group well-child care included structure (e.g., group size, facilitators), content (e.g., health assessments, service linkages). and process (e.g., interactive learning and community building). We found clinical outcomes in all four dimensions of the quadruple aim of healthcare.

CONCLUSION

Our conceptual framework can guide model implementation and identifies several outcomes that can be used to harmonize model evaluation and research. Future research and practice can use the conceptual framework as a tool to standardize model implementation and evaluation and generate evidence to inform future healthcare policy and practice.

Implementing a Post-Discharge Telemedicine Service Pilot to Enhance the Hospital to Home Transition

OBJECTIVES

The objectives of this study are to (1) describe our postdischarge telemedicine program and (2) evaluate program implementation.

METHODS

At our single-center tertiary care children's hospital, we launched our postdischarge telemedicine program in April 2020. We used the Template for Intervention Description and Replication framework to describe our pilot program and Proctor's conceptual framework to evaluate implementation over a 9-month period. Retrospective chart review was conducted. Descriptive analyses were used to compare demographics and health care reutilization rates across patients. Implementation outcomes included adoption (rate of scheduled visits) and feasibility (rate of completed visits). Effectiveness outcomes included the rate of postdischarge issues and unscheduled healthcare utilization.

RESULTS

We established a postdischarge telemedicine program for a general pediatric population that ensured follow-up at a time when in-person evaluation was limited because of the coronavirus disease 2019 pandemic. For implementation evaluation, we included all 107 patients in the pilot program. Adoption was 100% and feasibility was 58%. Eighty-two percent of patients completing a visit reported one or more postdischarge issues. There was no difference in health system reutilization between those who completed a visit and those who did not.

CONCLUSIONS

Implementation of a postdischarge telemedicine service is achievable and promotes early detection of failures in the hospital to home transition. Directions for future study will include rigorous program evaluation via telemedicine program assessment tools and sustainability efforts that build upon known implementation and health service outcomes.

Informed Consent in Paediatric Telemedicine: Challenge or Opportunity? A Scoping Review

The fundamental importance of informed consent as a prerequisite for the lawfulness of the medical act is an indisputable cornerstone of clinical practice. However, the provision of effective information and the collection of informed consent presents important critical issues in the underage patient, even considering that in general terms he or she does not have the power to directly express consent, which must be provided by parents or legal guardians. These critical issues are amplified in the context of telemedicine. The present study aims, through a scoping review of the literature of the past 10 years, to outline the operational practices adopted in the collection of informed consent from children in the context of telemedicine and to identify solutions devised to address the critical issues related to the provision of adequate information to the child in this particular care setting. The results of the research show that the activity of delivering adequate information to the child, itself complex, is made even more complex by the particular setting of telemedicine, which, however, could be effectively exploited to facilitate communication with the child patient.

Mixed methods evaluation of pediatric telehealth equity for patients/families who communicate in languages other than English

Background

Emerging research demonstrates telehealth disparities for patients who communicate in languages other than English. A better understanding of pediatric telehealth use with families who communicate in languages other than English is needed to inform interventions to promote telehealth equity.

Methods

We conducted a mixed methods study of telehealth care in a children's hospital health system using electronic health record data for outpatient video telehealth encounters from April 2020 to July 2021 and qualitative interviews with clinical staff and Spanish-speaking parents of telehealth patients.

Results

The 16-month study period included 102,387 telehealth encounters; 5% of which were encounters in languages other than English. 83% of languages other than English encounters were with patients/families with a preferred healthcare language of Spanish. 11% of providers conducted ≥10 languages other than English telehealth encounters. This subset of providers conducted 71% of all languages other than English encounters. We conducted 25 interviews with clinical staff (n=13) and parents (n=12). Common themes identified across interviews were: (I) technology barriers affect access to and quality of telehealth; (II) clinical staff and parents are uncertain about the future role of telehealth for patients/families who communicate in languages other than English; (III) the well-known impact of language barriers on in-person healthcare access and quality for patients who communicate in languages other than English is also evident in telehealth.

Conclusions

Patients who communicate in languages other than English were underrepresented among telehealth encounters and encounters were concentrated among few providers. Promoting equitable telehealth care requires investment to address technology barriers, increase the readiness of providers and clinics to provide telehealth care in languages other than English, and continued attention to reducing the healthcare impact of language barriers.

Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review

PURPOSE

Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH.

METHODS

We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible.

RESULTS

Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes.

DISCUSSION

This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.

Family Engagement in Services During COVID-19: A Mixed-Methods Study of Caregiver and Staff Perspectives

INTRODUCTION

We examined changes in family engagement before versus during the pandemic in pediatric and family services and perceived facilitators and barriers to family engagement.

METHOD

We employed a mixed-methods assessment of staff and caregiver perspectives related to pediatric and family medicine clinics and family resource centers in rural northern New England. We used narrative synthesis to analyze qualitative interviews (n = 29) and descriptive statistics for quantitative surveys (n = 108).

RESULTS

Staff felt they were not doing as well at engaging families during versus prepandemic, identifying numerous facilitators and barriers. We found differences in resources used by families before versus during the pandemic. We identified discordant perspectives between caregivers and staff regarding how well clinics and centers identified and responded to family needs.

DISCUSSION

Leaders in pediatrics, advanced practice nursing, and related fields can draw on our findings to decide what services and modalities they provide for postpandemic.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use

OBJECTIVE

To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties.

METHODS

In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use.

RESULTS

In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth.

CONCLUSIONS

Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

The Impact of the Early COVID-19 Global Pandemic on Children Undergoing Active Cancer Treatment and Their Parents

(1) Background: The COVID-19 global pandemic has impacted people worldwide with unique implications for vulnerable groups. In this cross-sectional study, we examined the impact of the early pandemic on children undergoing active cancer treatment and their parents. (2) Methods: In May 2020, 30 parents of children undergoing active cancer treatment completed an online survey regarding the impact of COVID-19 on their child's cancer care, perceived utility of telemedicine, and child and parent mental health status. (3) Results: Most participants (87%) reported that they did not experience any changes to major cancer treatments. Among those who reported using telemedicine, 78% reported this to be beneficial. Over half of the participants reported that their child's mental health status was worse now than prior to the COVID-19 global pandemic. Parent-reported child anxiety scores were significantly higher for those who reported changes to mental health care for their child compared to those who did not report the same, t(25.99) = -3.04, p = 0.005. (4) Conclusion: Child and parent mental health status were affected when compared to pre-pandemic. Telemedicine appears to be a promising complement to face-to-face meetings for some families and warrants further exploration.

Understanding Transgender and Gender-Diverse Youth's Experiences Receiving Care via Telemedicine: Qualitative Interview Study

BACKGROUND

Access to virtual care has increased since the beginning of the COVID-19 pandemic, yet little is known about transgender and gender-diverse (TGD) youth's experiences and perspectives on receiving care via telemedicine.

OBJECTIVE

The purpose of this study was to explore these experiences to (1) inform necessary changes to the provision of pediatric gender-affirming care and (2) help providers and health systems determine if and how telemedicine should be made available post pandemic.

METHODS

Youth (aged 14-17 years) who completed a telemedicine visit in the Seattle Children's Gender Clinic were invited to participate in a semistructured interview exploring perceived advantages or disadvantages of telemedicine and preferred visit modalities. Interview transcriptions were analyzed by 2 research team members using an inductive thematic analysis framework.

RESULTS

A total of 15 TGD youth completed an interview. Commonly cited advantages of telemedicine were convenience and comfort with having visits in their own environments. Reported disadvantages included technical issues, discomfort with the impersonal nature, lack of familiarity with the platform, and privacy concerns. Overall, slightly more youth preferred in-person visits over telemedicine, referencing both specific characteristics of the clinical visit (ie, initial vs return and complexity) and proximity to the clinic as reasons for this preference. Although a plurality of TGD youth preferred in-person visits, they also recognized the value of telemedicine and the impact it may have in facilitating access to care.

CONCLUSIONS

Given the variations in needs and visit complexity, our study supports the provision of both in-person and telemedicine modalities as options for pediatric gender-affirming care.

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Follow-Up Care amidst a Global Pandemic

STUDY OBJECTIVE

To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ² tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes.

RESULTS

Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities.

CONCLUSIONS

Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care.

Use of Telemedicine Healthcare Systems in Children and Adolescents with Chronic Disease or in Transition Stages of Life: Consensus Document of the Italian Society of Telemedicine (SIT), of the Italian Society of Preventive and Social Pediatrics (SIPPS), of the Italian Society of Pediatric Primary Care (SICuPP), of the Italian Federation of Pediatric Doctors (FIMP) and of the Syndicate of Family Pediatrician Doctors (SIMPeF)

Telemedicine is considered an excellent tool to support the daily and traditional practice of the health profession, especially when referring to the care and management of chronic patients. In a panorama in which chronic pathologies with childhood onset are constantly increasing and the improvement of treatments has allowed survival for them into adulthood, telemedicine and remote assistance are today considered effective and convenient solutions both for the chronic patient, who thus receives personalized and timely assistance, and for the doctors, who reduce the need for direct intervention, hospitalizations and consequent management costs. This Consensus document, written by the main Italian Scientific Societies involved in the use of telemedicine in pediatrics, has the objectives to propose an organizational model based on the relationships between the actors who participate in the provision of a telemedicine service aimed at minors with chronic pathologies, identifying specific project links between the areas of telemedicine in the developmental age from the first 1000 days of life to the age adult. The future scenario will have to be able to integrate digital innovation in order to offer the best care to patients and citizens. It will have to be able to provide the involvement of patients from the very beginning of the design of any care pathway, increasing where possible the proximity of the health service to citizens.

Scheduled and attended pediatric primary care telemedicine appointments during COVID-19

BACKGROUND

The aim of this study was to examine pediatric primary care telemedicine visit scheduling and attendance during the first year of telemedicine.

METHODS

Using electronic health record data from two academic pediatric primary care practices between April 2020-March 2021, we used Pearson χ² tests and logistic regression models to identify child-, family-, and appointment-level characteristics associated with scheduled and attended telemedicine appointments.

RESULTS

Among 5178 primary care telemedicine appointments scheduled during the 12-month period, the proportion of appointments scheduled differed over time for children in families with a language preference other than English or Spanish (4% quarter 1 vs. 6% in quarter 4, p = 0.01) and residing in ZIP codes with the lowest household technology access (24% in quarter 1 vs. 19% in quarter 3 (p = 0.01). Four thousand one hundred and forty-eight of 5178 scheduled telemedicine appointments were attended. Likelihood of attending a telemedicine appointment was highest for children in families with a language preference other than English or Spanish (90%, 95% CI 86-94% compared to Spanish 74%, 95% CI 65-84%), and same-day appointments (86%, 95% CI 85-87%). Attendance among families preferring Spanish language was higher in later months compared to earlier months.

CONCLUSIONS

We found disparities in scheduling and attending telemedicine appointments, but signs of greater language equity over time.