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Woodward EN, Castillo AIM, True G, Willging C, Kirchner JE. Challenges and promising solutions to engaging patients in healthcare implementation in the United States: an environmental scan. BMC Health Serv Res 2024; 24:29. [PMID: 38178131 PMCID: PMC10768202 DOI: 10.1186/s12913-023-10315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND One practice in healthcare implementation is patient engagement in quality improvement and systems redesign. Implementers in healthcare systems include clinical leadership, middle managers, quality improvement personnel, and others facilitating changes or adoption of new interventions. Patients provide input into different aspects of health research. However, there is little attention to involve patients in implementing interventions, especially in the United States (U.S.), and this might be essential to reduce inequities. Implementers need clear strategies to overcome challenges, and might be able to learn from countries outside the U.S. METHODS We wanted to understand existing work about how patients are being included in implementation activities in real world U.S. healthcare settings. We conducted an environmental scan of three data sources: webinars, published articles, and interviews with implementers who engaged patients in implementation activities in U.S. healthcare settings. We extracted, categorized, and triangulated from data sources the key activities, recurring challenges, and promising solutions using a coding template. RESULTS We found 27 examples of patient engagement in U.S. healthcare implementation across four webinars, 11 published articles, and seven interviews, mostly arranging patient engagement through groups and arranging processes for patients that changed how engaged they were able to be. Participants rarely specified if they were engaging a population experiencing healthcare inequities. Participants described eight recurring challenges; the two most frequently identified were: (1) recruiting patients representative of those served in the healthcare system; and (2) ensuring processes for equitable communication among all. We matched recurring challenges to promising solutions, such as logistic solutions on how to arrange meetings to enhance engagement or training in inclusivity and power-sharing. CONCLUSION We clarified how some U.S. implementers are engaging patients in healthcare implementation activities using less and more intensive engagement. It was unclear whether reducing inequities was a goal. Patient engagement in redesigning U.S. healthcare service delivery appears similar to or less intense than in countries with more robust infrastructure for this, such as Canada and the United Kingdom. Challenges were common across jurisdictions, including retaining patients in the design/delivery of implementation activities. Implementers in any region can learn from those in other places.
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Affiliation(s)
- Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA.
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA.
| | - Andrea Isabel Melgar Castillo
- VA Center for Mental Healthcare and Outcomes Research, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA
- Graduate School, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Gala True
- South Central Mental Illness Research Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal St, New Orleans, LA, 70119, USA
- Section on Community and Population Medicine, School of Medicine, Louisiana State University, 2400 Canal St (11F), New Orleans, LA, USA
| | - Cathleen Willging
- Pacific Institute for Research and Evaluation, 851 University Boulevard, Suite 101, Albuquerque, NM, 87106, USA
| | - JoAnn E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA
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Young K, Xiong T, Lee R, Banerjee AT, Leslie M, Ko WY, Pham Q. User-Centered Design and Usability of a Culturally Adapted Virtual Survivorship Care App for Chinese Canadian Prostate Cancer Survivors: Qualitative Descriptive Study. JMIR Hum Factors 2024; 11:e49353. [PMID: 38163295 PMCID: PMC10790201 DOI: 10.2196/49353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Cultural adaptations of digital health innovations are a growing field. However, digital health innovations can increase health inequities. While completing exploratory work for the cultural adaptation of the Ned Clinic virtual survivorship app, we identified structural considerations that provided a space to design digitally connected and collective care. OBJECTIVE This study used a community-based participatory research and user-centered design process to develop a cultural adaptation of the Ned Clinic app while designing to intervene in structural inequities. METHODS The design process included primary data collection and qualitative analysis to explore and distill design principles, an iterative design phase with a multidisciplinary team, and a final evaluation phase with participants throughout the design process as a form of member checking and validation. RESULTS Participants indicated that they found the final adapted prototype to be acceptable, appropriate, and feasible for their use. The changes made to adapt the prototype were not specifically culturally Chinese. Instead, we identified ways to strengthen connections between the survivor and their providers; improve accessibility to resources; and honor participants' desires for relationality, accountability, and care. CONCLUSIONS We grounded the use of user-centered design to develop a prototype design that supports the acts of caring through digital technology by identifying and designing to resist structures that create health inequities in the lives of this community of survivors. By designing for collective justice, we can provide accessible, feasible, and relational care with digital health through the application of Indigenous and Black feminist ways of being and knowing.
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Affiliation(s)
- Karen Young
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ting Xiong
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rachel Lee
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Ananya Tina Banerjee
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Myles Leslie
- School of Public Policy, University of Calgary, Calgary, AB, Canada
| | - Wellam Yu Ko
- Men's Health Research Program, University of British Columbia, Vancouver, BC, Canada
| | - Quynh Pham
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Telfer School of Management, University of Ottawa, Ottawa, ON, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
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Young K, Xiong T, Lee R, Banerjee AT, Leslie M, Ko WY, Guo JYJ, Pham Q. Honoring the Care Experiences of Chinese Canadian Survivors of Prostate Cancer to Cultivate Cultural Safety and Relationality in Digital Health: Exploratory-Descriptive Qualitative Study. J Med Internet Res 2023; 25:e49349. [PMID: 38153784 PMCID: PMC10784982 DOI: 10.2196/49349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/31/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Prostate cancer (PCa) is the most commonly diagnosed nonskin cancer for Canadian men and has one of the highest 5-year survival rates, straining systems to provide care. Virtual care can be one way to relieve this strain, but survivors' care needs and technology use are influenced by intersecting social and cultural structures. Cultural adaptation has been posited as an effective method to tailor existing interventions to better serve racialized communities, including Chinese men. However, cultural adaptations may inadvertently draw attention away from addressing structural inequities. OBJECTIVE This study used qualitative methods to (1) explore the perceptions and experiences of Chinese Canadian PCa survivors with follow-up and virtual care, and (2) identify implications for the cultural adaptation of a PCa follow-up care app, the Ned (no evidence of disease) Clinic. METHODS An axiology of relational accountability and a relational paradigm underpinned our phenomenologically informed exploratory-descriptive qualitative study design. A community-based participatory approach was used, informed by cultural safety and user-centered design principles, to invite Chinese Canadian PCa survivors and their caregivers to share their stories. Data were inductively analyzed to explore their unmet needs, common experiences, and levels of digital literacy. RESULTS Unmet needs and technology preferences were similar to broader trends within the wider community of PCa survivors. However, participants indicated that they felt uncomfortable, unable to, or ignored when expressing their needs. Responses spoke to a sense of isolation and reflected a reliance on culturally informed coping mechanisms, such as "eating bitterness," and familial assistance to overcome systemic barriers and gaps in care. Moreover, virtual care was viewed as "better than nothing;" it did not change a perceived lack of focus on improving quality of life or care continuity in survivorship care. Systemic changes were identified as likely to be more effective in improving care delivery and well-being rather than the cultural adaptation of Ned for Chinese Canadians. Participants' desires for care reflected accessibility issues that were not culturally specific to Chinese Canadians. CONCLUSIONS Chinese Canadian survivors are seeking to strengthen their connections in a health care system that provides privacy and accessibility, protects relationality, and promotes transparency, accountability, and responsibility. Designing "trickle-up" adaptations that address structural inequities and emphasize accessibility, relationality, and privacy may be more effective and efficient at improving care than creating cultural adaptations of interventions.
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Affiliation(s)
- Karen Young
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ting Xiong
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rachel Lee
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Ananya Tina Banerjee
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Myles Leslie
- School of Public Policy, University of Calgary, Calgary, AB, Canada
| | - Wellam Yu Ko
- Men's Health Research Program, University of British Columbia, Vancouver, BC, Canada
| | - Julia Yu Jia Guo
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Quynh Pham
- Centre for Digital Therapeutics, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Telfer School of Management, University of Ottawa, Ottawa, ON, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
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Polo J, Basile MJ, Zhang M, Ordonez K, Rodriguez D, Boye-Codjoe E, Williams M, Tsang D, Medina R, Jacome S, Mir P, Khanijo S, Pekmezaris R, Hajizadeh N. Application of the RE-AIM framework to evaluate the implementation of telehealth pulmonary rehabilitation in a randomized controlled trial among African-American and Hispanic patients with advanced stage Chronic Obstructive Pulmonary Disease. BMC Health Serv Res 2023; 23:515. [PMID: 37218000 DOI: 10.1186/s12913-023-09492-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/03/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Pulmonary rehabilitation (PR) decreases rehospitalization for people with COPD. However, less than 2% receive PR, partly due to lack of referral and sparsity of PR facilities. This disparity is particularly pronounced in African American and Hispanic persons with COPD. Telehealth-provided PR could increase access and improve health outcomes. METHODS We applied the RE-AIM framework in a post-hoc analysis of our mixed methods RCT comparing referral to Telehealth-delivered PR (TelePR) versus standard PR (SPR) for African American and Hispanic COPD patients hospitalized for COPD exacerbation. Both arms received a referral to PR for 8 weeks, social worker follow-up, and surveys administered at baseline, 8 weeks, 6, and 12 months. PR sessions were conducted twice a week for 90 min each (16 sessions total). Quantitative data were analyzed using 2-sample t tests or nonparametric Wilcoxon tests for continuous data and χ2/Fisher exact tests for categorical data. Logistic regression-estimated odds ratios (ORs) were used for the intention-to-treat primary outcome. Qualitative interviews were conducted at the end of the study to assess adherence and satisfaction and were analyzed using inductive and deductive methods. The goal was to understand Reach (whether the target population was able to be enrolled), Effectiveness (primary outcome was a composite of 6-month COPD rehospitalization and death), Adoption (proportion of people willing to initiate the program), Implementation (whether the program was able to be executed as intended, and Maintenance (whether the program was continued). RESULTS Two hundred nine people enrolled out of a 276-recruitment goal. Only 85 completed at least one PR session 57/111 (51%) TelePR; 28/98 (28%) SPR. Referral to TelePR compared to SPR did not decrease the composite outcome of 6-month COPD-readmission rate/death (OR1.35;95%CI 0.69,2.66). There was significant reduction in fatigue (PROMIS® scale) from baseline to 8-weeks in TelePR compared to SPR (MD-1.34; ± SD4.22; p = 0.02). Participants who received TelePR experienced improvements from baseline in several outcomes (ie, before and after 8 weeks of PR) in the following: COPD symptoms, knowledge about COPD management, fatigue, and functional capacity. Among the patients who had 1 initial visit, adherence rates were similar (TelePR arm, 59% of sessions; SPR arm, 63%). No intervention-related adverse events occurred. Barriers to PR adoption included difficulty or reluctance to complete medical clearances and beliefs about PR efficacy. Notably, only 9 participants sustained exercise after program completion. Maintenance of the program was not possible due to low insurance reimbursement and sparsity of Respiratory Therapists. CONCLUSIONS TelePR can reach COPD patients with health disparities and can be successfully implemented. The small sample size and large confidence intervals prevent conclusion about the relative effectiveness of participating in TelePR compared to SPR. However, improved outcomes were seen for those in TelePR as well as in SPR. Increasing adoption of PR and TelePR requires consideration of comorbidity burden, and perception of PR utility, and must facilitate medical clearances. Given the sparsity of SPR locations, TelePR can overcome at least the barrier of access. However, given the challenges to the uptake and completion of PR - many of the additional barriers in PR (both in TelePR and SPR) need to be addressed. Awareness of these real-world challenges will not only inform implementation of TelePR for clinicians seeking to adopt this platform but will also inform study designers and reviewers regarding the feasibility of approaches to patient recruitment and retention.
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Affiliation(s)
- Jennifer Polo
- Northwell Health, Great Neck, NY, USA.
- Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA.
| | - Melissa J Basile
- Northwell Health, Great Neck, NY, USA
- Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Meng Zhang
- Northwell Health, Great Neck, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | | | | | | | - Myia Williams
- Northwell Health, Great Neck, NY, USA
- Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | | | | | | | - Parvez Mir
- Wyckoff Heights Medical Center, Brooklyn, NY, USA
| | - Sameer Khanijo
- Northwell Health, Great Neck, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Renee Pekmezaris
- Northwell Health, Great Neck, NY, USA
- Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Department of Occupational Medicine, Epidemiology, and Prevention, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Negin Hajizadeh
- Northwell Health, Great Neck, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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An Q, Sandlund M, Agnello D, McCaffrey L, Chastin S, Helleday R, Wadell K. A scoping review of co-creation practice in the development of non-pharmacological interventions for people with Chronic Obstructive Pulmonary Disease: A health CASCADE study. Respir Med 2023; 211:107193. [PMID: 36889517 DOI: 10.1016/j.rmed.2023.107193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/28/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Incorporating co-creation processes may improve the quality of outcome interventions. However, there is a lack of synthesis of co-creation practices in the development of Non-Pharmacological Interventions (NPIs) for people with Chronic Obstructive Pulmonary Disease (COPD), that could inform future co-creation practice and research for rigorously improving the quality of care. OBJECTIVE This scoping review aimed to examine the co-creation practice used when developing NPIs for people with COPD. METHODS This review followed Arksey and O'Malley scoping review framework and was reported according to the PRISMA-ScR framework. The search included PubMed, Scopus, CINAHL, and Web of Science Core Collection. Studies reporting on the process and/or analysis of applying co-creation practice in developing NPIs for people with COPD were included. RESULTS 13 articles complied with the inclusion criteria. Limited creative methods were reported in the studies. Facilitators described in the co-creation practices included administrative preparations, diversity of stakeholders, cultural considerations, employment of creative methods, creation of an appreciative environment, and digital assistance. Challenges around the physical limitations of patients, the absence of key stakeholder opinions, a prolonged process, recruitment, and digital illiteracy of co-creators were listed. Most of the studies did not report including implementation considerations as a discussion point in their co-creation workshops. CONCLUSION Evidence-based co-creation in COPD care is critical for guiding future practice and improving the quality of care delivered by NPIs. This review provides evidence for improving systematic and reproducible co-creation. Future research should focus on systematically planning, conducting, evaluating, and reporting co-creation practices in COPD care.
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Affiliation(s)
- Qingfan An
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden.
| | - Marlene Sandlund
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Danielle Agnello
- School of Health and Life Sciences, Glasgow Caledonian University, UK
| | - Lauren McCaffrey
- School of Health and Life Sciences, Glasgow Caledonian University, UK
| | - Sebastien Chastin
- School of Health and Life Sciences, Glasgow Caledonian University, UK; Department of Movement and Sports Sciences, Ghent University, 9000, Ghent, Belgium
| | - Ragnberth Helleday
- Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Karin Wadell
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden
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Velez M, Lugo-Agudelo LH, Patiño Lugo DF, Glenton C, Posada AM, Mesa Franco LF, Negrini S, Kiekens C, Spir Brunal MA, Roberg ASB, Cruz Sarmiento KM. Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 2:CD014823. [PMID: 36780267 PMCID: PMC9918343 DOI: 10.1002/14651858.cd014823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve. OBJECTIVES To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation. SEARCH METHODS We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022. SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions. DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members. Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others. Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members. In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services. Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances. AUTHORS' CONCLUSIONS This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.
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Affiliation(s)
- Marcela Velez
- Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | | | - Claire Glenton
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Ana M Posada
- Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | | | - Stefano Negrini
- Department of Biomedical, Surgical and Dental Sciences, University La Statale , Milano, Italy
- Laboratory of Evidence Based Rehabilitation, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Ekwegh T, Cobb S, Adinkrah EK, Vargas R, Kibe LW, Sanchez H, Waller J, Ameli H, Bazargan M. Factors Associated with Telehealth Utilization among Older African Americans in South Los Angeles during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2675. [PMID: 36768041 PMCID: PMC9915549 DOI: 10.3390/ijerph20032675] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The COVID-19 pandemic transformed healthcare delivery with the expansive use of telemedicine. However, health disparities may result from lower adoption of telehealth among African Americans. This study examined how under-resourced, older African Americans with chronic illnesses use telehealth, including related sociodemographic and COVID-19 factors. METHODS Using a cross-sectional design, 150 middle-aged and older African Americans were recruited from faith-based centers from March 2021 to August 2022. Data collected included sociodemographics, comorbidities, technological device ownership, internet usage, and attitudes toward COVID-19 disease and vaccination. Descriptive statistics and multivariable regression models were conducted to identify factors associated with telehealth use. RESULTS Of the 150 participants, 32% had not used telehealth since the COVID-19 pandemic, with 75% reporting no home internet access and 38% having no cellular/internet network on their mobile device. Age, access to a cellular network on a mobile device, and wireless internet at home were significantly associated with the utilization of telehealth care. Higher anxiety and stress with an increased perceived threat of COVID-19 and positive attitudes toward COVID-19 vaccination were associated with telehealth utilization. DISCUSSION Access and integration of telehealth services were highlighted as challenges for this population of African Americans. To reduce disparities, expansion of subsidized wireless internet access in marginalized communities is necessitated. Education outreach and training by healthcare systems and community health workers to improve uptake of telehealth currently and post-COVID-19 should be considered.
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Affiliation(s)
- Tavonia Ekwegh
- Mervyn M. Dymally School of Nursing (MMDSON), Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Sharon Cobb
- Mervyn M. Dymally School of Nursing (MMDSON), Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Edward K. Adinkrah
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Roberto Vargas
- Department of Internal Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Lucy W. Kibe
- Physician Assistant Program, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Humberto Sanchez
- Office of Research, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Joe Waller
- Office of Research, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
| | - Hoorolnesa Ameli
- Department of Emergency Medicine, Mellie’s Bank Hospital, Tehran 1135933763, Iran
| | - Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA
- Department of Family Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90059, USA
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Baum SG, Coan LM, Porter AK. Meeting the needs of rural veterans through rapid implementation of pharmacist-provided telehealth management of diabetes during the COVID-19 pandemic. J Am Pharm Assoc (2003) 2022; 63:623-627. [PMID: 36379866 PMCID: PMC9569929 DOI: 10.1016/j.japh.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The rapid implementation of telehealth care owing to the coronavirus disease 2019 (COVID-19) pandemic allowed clinical pharmacist practitioners (CPPs) within the Veterans Health Administration (VA) to continue to provide diabetes management to veterans with health care disparities, including rural veterans. OBJECTIVES This project aimed to describe the change in hemoglobin A1c (HbA1c) in telehealth-naïve veterans with types 1 or 2 diabetes mellitus (DM) before and after the rapid implementation of CPP-provided telehealth DM management owing to the COVID-19 pandemic. The project also sought to describe potential health care disparities that may be addressed by the increase in telehealth use and the impact of metformin sustained action (SA) recalls. METHODS Analysis included patients receiving face-to-face DM-focused visits with a CPP before the COVID-19 pandemic (June 1, 2019, to December 1, 2019) who transitioned to telehealth care via telephone or VA Video Connect during the COVID-19 pandemic (June 1, 2020, to December 1, 2020). One or more HbA1c readings within each time frame was required for inclusion. Patients were excluded if previously enrolled in VA telehealth DM management. RESULTS The rapidly implemented telehealth management of DM provided by VA CPPs was observed to maintain or improve HbA1c control in 84.2% of patients. During the same time frame, 10.9% of patients were taken off metformin SA secondary to national drug recalls. In total, 76% of patients were from rural communities and > 52% of patients traveled greater than 50 miles round trip to receive face-to-face DM care before the pandemic. CONCLUSION Glycemic control was improved or maintained for most patients who were rapidly converted to pharmacist-provided telehealth DM management during the COVID-19 pandemic. A large majority of rural patients were reached as a result of CPP-provided telehealth care. This provides evidence to support the continued widespread telehealth utilization to effectively manage DM and reach veterans with health care disparities, particularly rural communities.
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9
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Santos CD, Rodrigues F, Caneiras C, Bárbara C. From Inception to Implementation: Strategies for Setting Up Pulmonary Telerehabilitation. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:830115. [PMID: 36188951 PMCID: PMC9397856 DOI: 10.3389/fresc.2022.830115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/24/2022] [Indexed: 11/13/2022]
Abstract
BackgroundThe emergence of innovative technology-enabled models of care is an opportunity to support more efficient ways of organizing and delivering healthcare services and improve the patient experience. Pulmonary telerehabilitation started as a promising area of research and became a strategic pandemic response to patients' decreased accessibility to rehabilitation care. Still, in the pre-COVID-19 era, we conducted a participatory study aiming to develop strategies for setting up pulmonary telerehabilitation as a person-centered digitally-enabled model of care.MethodsWe performed operational participatory research between June 2019 and March 2020 with the engagement of all stakeholders involved in the implementation of pulmonary telerehabilitation, including 14 people with Chronic Obstructive Pulmonary Disease. Patients were assessed subjectively and objectively pre and post a 3-month pulmonary rehabilitation program including exercise and education, which started in a face-to-face hospital setting during the first month and continued as a home-based, remotely supervised exercise training intervention.ResultsFive major groups of requirements targeted operational strategies for setting up pulmonary telerehabilitation: (1) pulmonary rehabilitation core principles, (2) quality and security standards, (3) technological functionality, (4) home environment appropriateness, and (5) telesetting skills. There was a statistical significance in the median change in the CAT score from 15.5 to 10.5 (p = 0.004) and in the PRAISE score from 49.5 to 53.0 (p = 0.006). Patients' mean levels of satisfaction regarding rehabilitation goals achievements were 88.1 ± 8.6% and the mean levels of satisfaction regarding the telerehabilitation experienced as a model of care were 95.4% ± 6.3%.ConclusionsThe success of telerehabilitation implementation was grounded on stakeholder engagement and targeted strategies for specific setup requirements, achieving patients' high satisfaction levels. Such operational experiences should be integrated into the redesigning of upgraded telerehabilitation programs as part of the solution to improve the effectiveness, accessibility, and resilience of health systems worldwide.
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Affiliation(s)
- Catarina Duarte Santos
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Unidade de Reabilitação Respiratória do Hospital Pulido Valente, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
- *Correspondence: Catarina Duarte Santos
| | - Fátima Rodrigues
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Unidade de Reabilitação Respiratória do Hospital Pulido Valente, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Cátia Caneiras
- Laboratório de Microbiologia na Saúde Ambiental (EnviHealthMicroLab), Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Healthcare Department, Nippon Gases Portugal, Vila Franca de Xira, Portugal
| | - Cristina Bárbara
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Serviço de Pneumologia, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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10
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Promoting Exercise Training Remotely. Life (Basel) 2022; 12:life12020262. [PMID: 35207549 PMCID: PMC8875216 DOI: 10.3390/life12020262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/24/2022] Open
Abstract
There has been increased incentivization to develop remote exercise training programs for those living with chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD). Remote programs offer patients an opportunity to overcome barriers to accessing traditional in-person programs, such as pulmonary rehabilitation (PR). Methods to deliver exercise training remotely range in complexity and types of technological modalities, including phone calls, real-time video conferencing, web- and app-based platforms, video games, and virtual reality (VR). There are a number of studies demonstrating the effectiveness of these programs on exercise capacity, dyspnea, and health-related quality of life (HRQL). However, there is great variation in these programs, making it difficult to assess findings across studies. Other aspects that contribute to the effectiveness of these programs include stakeholder perceptions, such as motivation and willingness to engage, and adherence. Finally, while the intent of these remote programs is to overcome barriers to access, they may inadvertently exacerbate access disparities. Future program development efforts should focus on standardizing how remote exercise training is delivered, engaging stakeholders early on to develop patient-centered programs that patients will want to use, and understanding the heterogeneous preferences and needs of those living with chronic respiratory disease in order to facilitate engagement with these programs.
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11
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Bailey JE, Gurgol C, Pan E, Njie S, Emmett S, Gatwood J, Gauthier L, Rosas LG, Kearney SM, Robler SK, Lawrence RH, Margolis KL, Osunkwo I, Wilfley D, Shah VO. Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review. J Med Internet Res 2021; 23:e28503. [PMID: 34878986 PMCID: PMC8693194 DOI: 10.2196/28503] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/04/2021] [Accepted: 10/03/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities. OBJECTIVE This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. METHODS A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. RESULTS PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. CONCLUSIONS Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.
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Affiliation(s)
- James E Bailey
- Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Cathy Gurgol
- Patient-Centered Outcomes Research Institute, Washington, DC, United States
| | - Eric Pan
- Westat Inc, Center for Healthcare Delivery Research and Evaluation, Rockville, MD, United States
| | - Shirilyn Njie
- Westat Inc, Center for Healthcare Delivery Research and Evaluation, Rockville, MD, United States
| | - Susan Emmett
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Duke Global Health Institute, Durham, NC, United States
| | - Justin Gatwood
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Lynne Gauthier
- Department of Physical Therapy and Kinesiology, Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, MA, United States
| | - Lisa G Rosas
- Department of Epidemiology and Population Health, Division of Primary Care and Population Health, Stanford School of Medicine, Palo Alto, CA, United States
- Department of Medicine, Division of Primary Care and Population Health, Stanford School of Medicine, Palo Alto, CA, United States
| | - Shannon M Kearney
- Solution Insights & Validation, Highmark Health, Pittsburgh, PA, United States
| | | | - Raymona H Lawrence
- Community Health Behavior and Education, Jiann-Ping College of Public Health, Georgia Southern University, Statesboro, GA, United States
| | | | - Ifeyinwa Osunkwo
- Cancer Care, Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - Denise Wilfley
- Department of Psychiatry, College of Medicine, Washington University in St. Louis, St Louis, MO, United States
| | - Vallabh O Shah
- Department of Internal Medicine and Biochemistry, School of Medicine, University of New Mexico, Albuquerque, NM, United States
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12
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Garvin LA, Hu J, Slightam C, McInnes DK, Zulman DM. Use of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness. J Gen Intern Med 2021; 36:2274-2282. [PMID: 34027612 PMCID: PMC8141357 DOI: 10.1007/s11606-021-06900-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Veterans experiencing homelessness face substantial barriers to accessing health and social services. In 2016, the Veterans Affairs (VA) healthcare system launched a unique program to distribute video-enabled tablets to Veterans with access barriers. OBJECTIVE Evaluate the use of VA-issued video telehealth tablets among Veterans experiencing homelessness in the VA system. DESIGN Guided by the RE-AIM framework, we first evaluated the adoption of tablets among Veterans experiencing homelessness and housed Veterans. We then analyzed health record and tablet utilization data to compare characteristics of both subpopulations, and used multivariable logistic regression to identify factors associated with tablet use among Veterans experiencing homelessness. PATIENTS In total, 12,148 VA patients receiving tablets between October 2017 and March 2019, focusing on the 1470 VA Veterans experiencing homelessness receiving tablets (12.1%). MAIN MEASURES Tablet use within 6 months of receipt for mental health, primary or specialty care. KEY RESULTS Nearly half (45.9%) of Veterans experiencing homelessness who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among Veterans experiencing homelessness who were younger (AOR = 2.77; P <.001); middle-aged (AOR = 2.28; P <.001); in rural settings (AOR = 1.46; P =.005); and those with post-traumatic stress disorder (AOR = 1.64; P <.001), and less common among those who were Black (AOR = 0.43; P <.001) and those with a substance use disorder (AOR = 0.59; P <.001) or persistent housing instability (AOR = 0.75; P = .023). CONCLUSIONS Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond. VA's distribution of video telehealth tablets offers healthcare access to Veterans experiencing homelessness; however, barriers remain for subpopulations. Tailored training and support for these patients may be needed to optimize telehealth tablet use and effectiveness.
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Affiliation(s)
- Lynn A Garvin
- VA Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 S. Huntington Avenue, Bldg 9, Rm 225, Boston, MA, 02130, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Jiaqi Hu
- VA Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Cindie Slightam
- VA Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - D Keith McInnes
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- VA Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Donna M Zulman
- VA Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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13
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Cox NS, Dal Corso S, Hansen H, McDonald CF, Hill CJ, Zanaboni P, Alison JA, O'Halloran P, Macdonald H, Holland AE. Telerehabilitation for chronic respiratory disease. Cochrane Database Syst Rev 2021; 1:CD013040. [PMID: 33511633 PMCID: PMC8095032 DOI: 10.1002/14651858.cd013040.pub2] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease. OBJECTIVES To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease. SEARCH METHODS We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts. SELECTION CRITERIA All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation. DATA COLLECTION AND ANALYSIS We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation. MAIN RESULTS We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation. AUTHORS' CONCLUSIONS This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.
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Affiliation(s)
- Narelle S Cox
- Institute for Breathing and Sleep, Melbourne, Australia
- Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
| | - Simone Dal Corso
- Graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Henrik Hansen
- Respiratory Research Unit, Department of Respiratory Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Christine F McDonald
- Institute for Breathing and Sleep, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Hospital, Melbourne, Australia
| | - Catherine J Hill
- Institute for Breathing and Sleep, Melbourne, Australia
- Department of Physiotherapy, Austin Hospital, Melbourne, Australia
| | - Paolo Zanaboni
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jennifer A Alison
- Discipline of Physiotherapy, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Allied Health Research and Education Unit, Sydney Local Health District, Sydney, Australia
| | - Paul O'Halloran
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Heather Macdonald
- Community Rehabilitation, Wimmera Health Care Group, Horsham, Australia
| | - Anne E Holland
- Institute for Breathing and Sleep, Melbourne, Australia
- Physiotherapy, Alfred Health, Melbourne, Australia
- Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
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Kumar R, Yee ML, Goh GB, Chia PY, Lee HL, Xin X, Teo PS, Ekstrom VS, Tan JY, Cheah MC, Wang YT, Chang JP, Tan CK, Tan HK, Krishnamoorthy TL, Chow WC. Virtual monitoring for stable chronic hepatitis B patients does not reduce adherence to medications: A randomised controlled study. J Telemed Telecare 2021; 29:261-270. [PMID: 33461398 DOI: 10.1177/1357633x20980298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Chronic hepatitis B (CHB) remains common in endemic regions, causing significant healthcare burden. Patients with CHB may need to be adherent to nucleoside analogue (NA) for a long period of time to prevent complications. This study aims to investigate the safety, efficacy and patient experience of a virtual monitoring clinic (VMC) in monitoring stable patients taking NA for CHB. METHODS Patients on NA and regular follow-up were randomised to either VMC alternating with doctors' clinic visit or to a control group in which they continued standard follow-up by doctors. Therapy adherence was measured by medication possession ratio (MPR) for NA therapy, incidence of virological breakthrough and hepatocellular carcinoma (HCC) development at two years of follow-up. Patient acceptance was measured on a Likert scale of 1-10. RESULTS A total 192 patients completed follow-up: 94 and 98 patients in the VMC and control groups, respectively. Mean age was 60.6 ± 10.8 years, with 95.3% Chinese ethnicity and 64.1% males. Age, gender, race, educational, employment and financial status were similar in both groups. Upon study completion, the majority of patients - 76 (80.9%) in VMC group and 74 (75.5%) in control group - had MPR ≥0.8; 88.8% were satisfied and rated VMC better than a traditional follow-up clinic with doctors only. More than 85% of patients rated ≥8/10 on the Likert scale for VMC, and preferred VMC over traditional clinic visits. Clinical outcomes observed were HCC development in one (1.1%) in the VMC group and four (4.1%) in the control group (p = 0.369). Two (2.1%) and one (1.0%) virological breakthroughs were observed in the VMC and control groups, respectively (p = 0.615). No incidence of HCC or abnormal blood tests were missed in the VMC arm. DISCUSSION VMC is a viable and safe clinical model for monitoring stable CHB patients on NA therapy without compromising patients' adherence to medications and is preferred by patients.
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Affiliation(s)
- Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Mei-Ling Yee
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - George Bb Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Pei-Yuh Chia
- Department of Nursing, Singapore General Hospital, Singapore
| | - Hwei-Ling Lee
- Department of Nursing, Singapore General Hospital, Singapore
| | - X Xin
- Health Services Research Unit, Research Office, Singapore General Hospital, Singapore
| | - Pek Se Teo
- Health Services Research Unit, Research Office, Singapore General Hospital, Singapore
| | - Victoria Sm Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Jin Yt Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Mark Cc Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Yu T Wang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Jason Pe Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Chee-Keat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Hiang Keat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Thinesh L Krishnamoorthy
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Wan-Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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15
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Pekmezaris R, Williams MS, Pascarelli B, Finuf KD, Harris YT, Myers AK, Taylor T, Kline M, Patel VH, Murray LM, McFarlane SI, Pappas K, Lesser ML, Makaryus AN, Martinez S, Kozikowski A, Polo J, Guzman J, Zeltser R, Marino J, Pena M, DiClemente RJ, Granville D. Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study. BMC Med Inform Decis Mak 2020; 20:324. [PMID: 33287815 PMCID: PMC7720574 DOI: 10.1186/s12911-020-01346-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/22/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.
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Affiliation(s)
- Renee Pekmezaris
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA.
| | - Myia S Williams
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Briana Pascarelli
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Kayla D Finuf
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA.
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA.
| | - Yael T Harris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY, USA
| | - Alyson K Myers
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY, USA
| | - Tonya Taylor
- College of Medicine, Division of Infectious Disease, SUNY-Downstate Health Sciences University, Brooklyn, NY, USA
| | - Myriam Kline
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Vidhi H Patel
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Lawrence M Murray
- Annie E. Casey Foundation Children and Family Fellowship, Baltimore, MD, USA
| | - Samy I McFarlane
- Department of Medicine, SUNY-Downstate Health Sciences University, Brooklyn, NY, USA
| | - Karalyn Pappas
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Martin L Lesser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Amgad N Makaryus
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY, USA
| | - Sabrina Martinez
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Andrjez Kozikowski
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | | | | | - Roman Zeltser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Nassau University Medical Center, East Meadow, NY, USA
| | - Jose Marino
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Maria Pena
- Nassau University Medical Center, East Meadow, NY, USA
- Mount Sinai Hospital, Mount Sinai Health System, New York, NY, USA
| | - Ralph J DiClemente
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, USA
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16
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Odonkor CA, Esparza R, Flores LE, Verduzco-Gutierrez M, Escalon MX, Solinsky R, Silver JK. Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review. PM R 2020; 13:180-203. [PMID: 33090686 DOI: 10.1002/pmrj.12509] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 01/18/2023]
Abstract
Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.
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Affiliation(s)
- Charles A Odonkor
- Department of Orthopaedics and Rehabilitation, Division of Physiatry, Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Rachel Esparza
- Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Laura E Flores
- College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Miguel X Escalon
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Solinsky
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Julie K Silver
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA.,Massachusetts General Hospital, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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