Using noninferiority tests to evaluate telemedicine and e-health services: systematic review

Environmental Factors for Sustained Telehealth Use in Mental Health Services: A Mixed Methods Analysis

Background: The mental health service delivery gap remains high globally. Appropriate telehealth use may increase capacity through flexible remote care provision. Despite the historical lack of telehealth integration into publicly funded mental health services, during COVID-19 lockdowns, services rapidly switched to telephone and audiovisual care provision. In Aotearoa New Zealand (NZ), this was abandoned when no longer required by COVID-19 restrictions. This study explores environmental factors associated with telehealth implementation and ongoing use or discontinuation across a multiregional outpatient mental health service. This work contributes to understanding system-level factors influencing telehealth use and thus informs policy and practice in postpandemic environments. Methods: This mixed methods study applied an interpretive description methodology. Semistructured interviews with 33 mental health clinicians were thematically analysed. Qualitative findings were reframed and evaluated using time series analyses of population-level quantitative data (prior to and throughout the pandemic). Findings were synthesised with qualitative themes to develop an understanding of environmental factors contributing to telehealth use. Results: Findings highlighted an increase in clients assessed by mental health services and declining clinician numbers, contributing to pressure placed on clinicians. There was a lack of culture supporting telehealth, including limited awareness, leadership, and champions to facilitate implementation. Some teams provided services suited to telehealth; other subspeciality teams had limited applications for telehealth. There was a general lack of policy and guidelines to support telehealth use and limited technical support for clinicians unfamiliar with audiovisual software. Conclusion: Disorganised telehealth adoption in the study regions provides insight into wider environmental drivers affecting telehealth uptake. For telehealth to become a workable service delivery mode following COVID-19, stewardship and culture shifts are required, including policy development, technical support, and resources to support clinical teams. Telehealth may address growing service demand by improving interfaces with primary care and providing timely access to specialist input.

Global Implications From the Rise and Recession of Telehealth in Aotearoa New Zealand Mental Health Services During the COVID-19 Pandemic: Mixed Methods Study

BACKGROUND

The COVID-19 pandemic accelerated the adoption of telehealth services for remote mental health care provision. Although studies indicate that telehealth can enhance the efficiency of service delivery and might be favored or even preferred by certain clients, its use varied after the pandemic. Once the pandemic-related restrictions eased, some regions curtailed their telehealth offerings, whereas others sustained them. Understanding the factors that influenced these decisions can offer valuable insights for evidence-based decision-making concerning the future of telehealth in mental health services.

OBJECTIVE

This study explored the factors associated with the uptake of and retreat from telehealth across a multiregional outpatient mental health service in Aotearoa New Zealand. We aimed to contribute to the understanding of the factors influencing clinicians' use of telehealth services to inform policy and practice.

METHODS

Applying an interpretive description methodology, this sequential mixed methods study involved semistructured interviews with 33 mental health clinicians, followed by a time-series analysis of population-level quantitative data on clinician appointment activities before and throughout the COVID-19 pandemic. The interviews were thematically analyzed, and select themes were reframed for quantitative testing. The time-series analysis was conducted using administrative data to explore the extent to which these data supported the themes. In total, 4,117,035 observations were analyzed between October 1, 2019, and August 1, 2022. The findings were then synthesized through the rereview of qualitative themes.

RESULTS

The rise and recession of telehealth in the study regions were related to 3 overarching themes: clinician preparedness and role suitability, population determinants, and service capability. Participants spoke about the importance of familiarity and training but noted differences between specialist roles. Quantitative data further suggested differences based on the form of telehealth services offered (eg, audiovisual or telephone). In addition, differences were noted based on age, gender, and ethnicity; however, clinicians recognized that effective telehealth use enabled clinicians' flexibility and client choice. In turn, clinicians spoke about system factors such as telehealth usability and digital exclusion that underpinned the daily functionality of telehealth.

CONCLUSIONS

For telehealth services to thrive when they are not required by circumstances such as pandemic, investment is needed in telehealth training for clinicians, digital infrastructure, and resources for mental health teams. The strength of this study lies in its use of population-level data and consideration of a telehealth service operating across a range of teams. In turn, these findings reflect the voice of a variety of mental health clinicians, including teams operating from within specific cultural perspectives.

Comparing telemedicine and in-person gastrointestinal cancer genetic appointment outcomes during the COVID-19 pandemic

BACKGROUND

The study purpose is to compare outcomes associated with completion of genetic testing between telemedicine and in-person gastrointestinal cancer risk assessment appointments during the COVID-19 pandemic.

METHODS

Data was collected on patients with scheduled appointments between July 2020 and June 2021 in a gastrointestinal cancer risk evaluation program (GI-CREP) that utilized both telemedicine and in-person visits throughout the COVID-19 pandemic, and a survey was administered.

RESULTS

A total of 293 patients had a GI-CREP appointment scheduled and completion rates of in-person versus telemedicine appointments were similar. Individuals diagnosed with cancer and those with Medicaid insurance had lower rates of appointment completion. Although telehealth was the preferred visit modality, there were no differences in recommending genetic testing nor in the consent rate for genetic testing between in-person and telemedicine visits. However, of patients who consented for genetic testing, more than three times more patients seen via telemedicine did not complete genetic testing compared to those seen in-person (18.3% versus 5.2%, p = 0.008). Furthermore, telemedicine visits had a longer turnaround time for genetic test reporting (32 days versus 13 days, p < 0.001).

CONCLUSIONS

Compared to in-person GI-CREP appointments, telemedicine was associated with lower rates of genetic testing completion, and longer turnaround time for results.

Prediction model study focusing on eHealth in the management of urinary incontinence: the Personalised Advantage Index as a decision-making aid

OBJECTIVE

To develop a prediction model and illustrate the practical potential of personalisation of treatment decisions between app-based treatment and care as usual for urinary incontinence (UI).

DESIGN

A prediction model study using data from a pragmatic, randomised controlled, non-inferiority trial.

SETTING

Dutch primary care from 2015, with social media included from 2017. Enrolment ended on July 2018.

PARTICIPANTS

Adult women were eligible if they had ≥2 episodes of UI per week, access to mobile apps and wanted treatment. Of the 350 screened women, 262 were eligible and randomised to app-based treatment or care as usual; 195 (74%) attended follow-up.

PREDICTORS

Literature review and expert opinion identified 13 candidate predictors, categorised into two groups: Prognostic factors (independent of treatment type), such as UI severity, postmenopausal state, vaginal births, general physical health status, pelvic floor muscle function and body mass index; and modifiers (dependent on treatment type), such as age, UI type and duration, impact on quality of life, previous physical therapy, recruitment method and educational level.

MAIN OUTCOME MEASURE

Primary outcome was symptom severity after a 4-month follow-up period, measured by the International Consultation on Incontinence Questionnaire the Urinary Incontinence Short Form. Prognostic factors and modifiers were combined into a final prediction model. For each participant, we then predicted treatment outcomes and calculated a Personalised Advantage Index (PAI).

RESULTS

Baseline UI severity (prognostic) and age, educational level and impact on quality of life (modifiers) independently affected treatment effect of eHealth. The mean PAI was 0.99±0.79 points, being of clinical relevance in 21% of individuals. Applying the PAI also significantly improved treatment outcomes at the group level.

CONCLUSIONS

Personalising treatment choice can support treatment decision making between eHealth and care as usual through the practical application of prediction modelling. Concerning eHealth for UI, this could facilitate the choice between app-based treatment and care as usual.

TRIAL REGISTRATION NUMBER

NL4948t.

Examining clinicians' concerns delivering telemental health interventions directly to autistic individuals during COVID-19

Background

The COVID-19 pandemic necessitated the adoption of telemental health (TMH). Pre-pandemic, clinicians had voiced many TMH concerns, but these had not been investigated with respect to autism spectrum disorder (ASD) even with it being known that there are distinct ASD-associated challenges for in-person mental health interventions.

Method

A convenience sample of (n = 55) clinicians completed an online survey regarding their perspectives of adopting TMH interventions in ASD, with closed- and open-answered questions. Quantitative and qualitative data were analysed descriptively/inferentially and via Content Analysis, respectively.

Results

Multiple clinicians endorsed each TMH challenges/barrier previously identified as concerns in the non-ASD literature. However, overall levels of concern over challenges/barriers were low, and challenges were more likely to be predicted than experienced and considered to be case/presentation specific. Challenges that were considered ASD-specific included the exacerbation of those associated with in-person delivery in ASD, alongside difficulties with trust and appropriate remote social behaviour. On average, clinicians indicated a preference for 50% TMH interventions post-pandemic. Clinicians' perceived technological competence and extent of professional experience with ASD were not significantly associated with levels of concern, nor number of experienced challenges, with TMH interventions in ASD.

Conclusion

In support of the existing TMH literature, challenges/barriers were more likely to be predicted than experienced and were considered to be case/presentation-specific, though this may be more variable in ASD owing to the well-established marked heterogeneity in this population. Remote provision of interventions exacerbated in-person ASD-associated challenges, as predicted, but clinician-level factors appeared not to impact TMH perceptions.

Evaluating the Use of Telepractice for Bottle-Feeding Assessments

There is currently limited evidence supporting the use of telepractice to conduct bottle-feeding assessments. This study aimed to investigate the inter-rater reliability of bottle-feeding assessments conducted via synchronous telepractice (real-time videoconferencing). Secondary aims were to investigate parent and clinician satisfaction. Bottle-feeding skills of 30 children (aged 1 month-2 years) were simultaneously assessed by a telepractice SP (T-SP) at a remote location and an in-person SP (IP-SP) at the family home. A purpose-designed assessment form was used to evaluate: (1) developmental level (screen only), (2) state, color, and respiration, (3) oral motor skills, (4), infant oral reflexes, (5) tongue tie (screen only), (6) non-nutritive suck, (7) bottle-feeding, (8) overall feeding skills and (9) recommendations. Results of the T-SP and IP-SP assessments were compared using agreement statistics. Parents reported perceptions of telepractice pre and post session, and also rated post-session satisfaction. The telepractice SP completed a satisfaction questionnaire post-appointment. The majority of assessment components (45/53, 85%) met the agreement criteria (≥80% exact agreement). Difficulties were noted for the assessment of palate integrity, gagging during non-nutritive suck assessment, and 6 components of the tongue tie screen. Parent and clinician satisfaction was high; SPs reported that they would offer telepractice services to 93% of families again in the future. Overall, the results demonstrated that most components of a bottle-feeding assessment could be reliably completed via synchronous telepractice in family homes. However, further research is required to improve the reliability of some intra-oral assessment components.

Evaluating the Use of Telepractice to Deliver Pediatric Feeding Assessments

Purpose This study aimed to investigate the interrater reliability of pediatric feeding assessments conducted via synchronous (real-time) telepractice. Secondary aims were to investigate parent and clinician satisfaction. Method The eating and/or cup drinking skills of 40 children (aged 4 months to 7 years) were simultaneously assessed by one speech-language pathologist (SLP) leading the appointment via telepractice and a second SLP present in the family home. A purpose-designed assessment form was used to assess (a) positioning, (b) development, (c) oral sensorimotor function, (d) prefeeding respiratory status, (e) observation of eating and drinking, (f) parent-child interaction, (g) overall feeding skills, and (h) feeding recommendations. The telepractice SLP completed a postappointment satisfaction questionnaire, and parents completed five questionnaires specifically investigating perceptions of and satisfaction with the telepractice feeding appointment. Results Agreement for all assessment components except intraoral examination (palate integrity and tonsils) was > 85%. All appointments were able to be conducted via telepractice, and for 90% of these (n = 36), clinicians agreed that telepractice was an effective service delivery method. Parents reported high levels of satisfaction with telepractice, with 76% reporting that the telepractice appointment was similar to a traditional in-person appointment. Conclusion Study results demonstrated that synchronous pediatric feeding assessments conducted in family homes via telepractice were feasible, reliable, and acceptable to both clinicians and parents. Supplemental Material https://doi.org/10.23641/asha.14700228.

Evaluation of the triple aim of medicine in prehospital telemedicine: A systematic literature review

OBJECTIVES

With telemedicine becoming more widely implemented in emergency situations, understanding the quality and content of current findings that explore prehospital telemedicine is vital to establish best practices and guide future research. This systematic review examines the clinical importance of telemedicine in patient-provider ambulance-based settings with a focus on multifunctional systems for general prehospital emergency populations.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology we found 1564 abstracts, which were blind-reviewed by independent reviewers. Relevant articles were reviewed, classified, and analyzed according to research methods and technology type, as well as quality, cost, and satisfaction. The studies were also reviewed for validated evidence-based practice.

RESULTS

Those studies that looked at cost, quality, and satisfaction with care generally shared favorable results. Setup notwithstanding, cost was comparable or less than controls. Care quality was also found to be in line with or slightly preferable to face-to-face care with some advantages in response time and quality. Patients and providers were satisfied with the systems. Common obstacles included limited bandwidth and small sample sizes.

CONCLUSIONS

Although feasibility remains salient, research regarding the impact of ambulance-based telemedicine on patients and healthcare providers is encouraging, but nascent. As a whole, this body of literature does not yet adequately speak to the most important concerns of medicine: quality, cost, and satisfaction. More research is needed in each of these areas. However, those studies that do address these matters share hopeful results. Future research should test these mechanisms in prehospital settings with greater rigor.

Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study

BACKGROUND

Despite the increase in use and high expectations of digital health solutions, scientific evidence about the effectiveness of electronic health (eHealth) and other aspects such as usability and accuracy is lagging behind. eHealth solutions are complex interventions, which require a wide array of evaluation approaches that are capable of answering the many different questions that arise during the consecutive study phases of eHealth development and implementation. However, evaluators seem to struggle in choosing suitable evaluation approaches in relation to a specific study phase.

OBJECTIVE

The objective of this project was to provide a structured overview of the existing eHealth evaluation approaches, with the aim of assisting eHealth evaluators in selecting a suitable approach for evaluating their eHealth solution at a specific evaluation study phase.

METHODS

Three consecutive steps were followed. Step 1 was a systematic scoping review, summarizing existing eHealth evaluation approaches. Step 2 was a concept mapping study asking eHealth researchers about approaches for evaluating eHealth. In step 3, the results of step 1 and 2 were used to develop an "eHealth evaluation cycle" and subsequently compose the online "eHealth methodology guide."

RESULTS

The scoping review yielded 57 articles describing 50 unique evaluation approaches. The concept mapping study questioned 43 eHealth researchers, resulting in 48 unique approaches. After removing duplicates, 75 unique evaluation approaches remained. Thereafter, an "eHealth evaluation cycle" was developed, consisting of six evaluation study phases: conceptual and planning, design, development and usability, pilot (feasibility), effectiveness (impact), uptake (implementation), and all phases. Finally, the "eHealth methodology guide" was composed by assigning the 75 evaluation approaches to the specific study phases of the "eHealth evaluation cycle."

CONCLUSIONS

Seventy-five unique evaluation approaches were found in the literature and suggested by eHealth researchers, which served as content for the online "eHealth methodology guide." By assisting evaluators in selecting a suitable evaluation approach in relation to a specific study phase of the "eHealth evaluation cycle," the guide aims to enhance the quality, safety, and successful long-term implementation of novel eHealth solutions.

Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study

BACKGROUND

Despite the increase in use and high expectations of digital health solutions, scientific evidence about the effectiveness of electronic health (eHealth) and other aspects such as usability and accuracy is lagging behind. eHealth solutions are complex interventions, which require a wide array of evaluation approaches that are capable of answering the many different questions that arise during the consecutive study phases of eHealth development and implementation. However, evaluators seem to struggle in choosing suitable evaluation approaches in relation to a specific study phase.

OBJECTIVE

The objective of this project was to provide a structured overview of the existing eHealth evaluation approaches, with the aim of assisting eHealth evaluators in selecting a suitable approach for evaluating their eHealth solution at a specific evaluation study phase.

METHODS

Three consecutive steps were followed. Step 1 was a systematic scoping review, summarizing existing eHealth evaluation approaches. Step 2 was a concept mapping study asking eHealth researchers about approaches for evaluating eHealth. In step 3, the results of step 1 and 2 were used to develop an "eHealth evaluation cycle" and subsequently compose the online "eHealth methodology guide."

RESULTS

The scoping review yielded 57 articles describing 50 unique evaluation approaches. The concept mapping study questioned 43 eHealth researchers, resulting in 48 unique approaches. After removing duplicates, 75 unique evaluation approaches remained. Thereafter, an "eHealth evaluation cycle" was developed, consisting of six evaluation study phases: conceptual and planning, design, development and usability, pilot (feasibility), effectiveness (impact), uptake (implementation), and all phases. Finally, the "eHealth methodology guide" was composed by assigning the 75 evaluation approaches to the specific study phases of the "eHealth evaluation cycle."

CONCLUSIONS

Seventy-five unique evaluation approaches were found in the literature and suggested by eHealth researchers, which served as content for the online "eHealth methodology guide." By assisting evaluators in selecting a suitable evaluation approach in relation to a specific study phase of the "eHealth evaluation cycle," the guide aims to enhance the quality, safety, and successful long-term implementation of novel eHealth solutions.

Noninferiority testing for matched-pair ordinal data with misclassification

New treatments that are noninferior or equivalent to-but not necessarily superior to-the reference treatment may still be beneficial to patients because they have fewer side effects, are more convenient, take less time, or cost less. The noninferiority test is widely used in medical research to provide guidance in such situation. In addition, categorical variables are frequently encountered in medical research, such as in studies involving patient-reported outcomes. In this paper, we develop a noninferiority testing procedure for correlated ordinal categorical variables based on a paired design with a latent normal distribution approach. Misclassification is frequently encountered in the collection of ordinal categorical data; therefore, we further extend the procedure to account for misclassification using information in the partially validated data. Simulation studies are conducted to investigate the accuracy of the estimates, the type I error rates, and the power of the proposed procedure. Finally, we analyze one substantive example to demonstrate the utility of the proposed approach.

A Review of Randomized Controlled Trials Utilizing Telemedicine for Improving Heart Failure Readmission: Can a Realist Approach Bridge the Translational Divide?

Background:

Telemedicine and digital health technologies hold great promise for improving clinical care of heart failure. However, inconsistent and contradictory findings from randomized controlled trials have so far discouraged widespread adoption of digital health in routine clinical practice. We undertook this review study to summarize the study outcomes of the use of exploring the evidence for telemedicine in the clinical care of patients with heart failure and readmissions.

Methods:

We inspected the references of guidelines and searched PubMed for randomized controlled trials published over the past 10 years on the use of telemedicine for reducing readmission in heart failure. We utilized a modified realist review approach to identify the underlying contextual mechanisms for the intervention(s) in each randomized controlled trial, evaluating outcomes of the intervention and understanding how and under what conditions they worked. To provide uniformity, all extracted data were synthesized using adapted domains from the taxonomy for disease management created by the Disease Management Taxonomy Writing Group.

Results:

A total of 12 papers were eligible, 6 of them supporting and 6 others undermining the use of telemedicine for improving heart failure readmission. In general terms, those studies not supporting the use of telemedicine were multicentre, publicly funded, with large amount of participants, and long duration. The patients had also better rates of treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker and beta-blockers, and telemonitoring and automatic transmission of vital signs were less utilized, in comparison with the studies in which telemedicine use was supported. The analysis of the environment, intensity, content of interventions, method of communication, quality of the underlying model of care and the ability, capability, and interest from health workers can help us to envisage probabilities of success of telemedicine use.

Conclusions:

A realist lens may aid to understand whom and in which circumstances the use of telemedicine can add any substantial value to traditional models of care. Wider outcome criteria beyond major adverse cardiovascular events, for example, cost efficacy, should also be considered as appropriate for effecting guidelines on care delivery when robust prognostic therapeutics already exist.

Women's Attitudes Toward Self-Monitoring of Their Pregnancy Using Noninvasive Electronic Devices: Cross-Sectional Multicenter Study

Background

Pregnancy can be distressing, particularly if expectant mothers are worried about the well-being of their fetus. Consequently, the desire for reassurance and frequent fetal monitoring is often pronounced. Smart wearable devices and telemedicine are promising tools that could assist women in self-monitoring their pregnancy at home, hence disburdening emergency departments (EDs). They present the possibility to clarify the need for urgent care remotely and offer tighter pregnancy monitoring. However, patients’ acceptance of such new technologies for fetal monitoring has not yet been explored extensively.

Objective

This survey aimed to elucidate the attitudes of women toward self-monitoring of their pregnancy using noninvasive electronic devices. The technical details of the proposed devices were not specified.

Methods

A cross-sectional multicenter study was conducted at the departments of obstetrics of the University Hospitals of Heidelberg and Leipzig, Germany. All patients seen in the obstetrics clinic who were above 18 years were offered participation. We designed a survey questionnaire including validated instruments covering population characteristics, issues in current and past pregnancies, as well as attitudes toward self-monitoring of pregnancy with smart devices.

Results

A total of 509 pregnant women with no previous experience in telemedicine participated. Only a small minority of 5.9% (29/493) regarded self-monitoring with wearable devices as an alternative to consulting their physicians. Along these lines, only 7.7% (38/496) strongly believed they would visit the ED less often if such devices were readily available. However, if the procedure were combined with a Web-based telemetric physician consult, 13.5% (66/487) would be highly motivated to use the devices. Furthermore, significantly more women regarded it as an alternative prior to seeing a doctor when they perceived a decline in fetal movements (P<.001). Interestingly, women with university degrees had a higher propensity to engage in pregnancy self-monitoring compared with women without one (37% vs 23%; P=.001). Of the participants, 77.9% (381/489) would like smart wearable devices to measure fetal heart sounds, and 62.6% (306/489) wished to use the devices on their own. Feedback from a doctor or midwife was also very important in their choice of such devices (61.8%, 301/487 wished feedback). The intended frequency of use differed vastly among women, ranging from 13.8% (65/471) who would like to use such a device several times per day to 31.6% (149/471) who favored once per week at most.

Conclusions

Our results point to a skeptical attitude toward pregnancy self-monitoring among pregnant women. Nevertheless, many women are open to using devices for pregnancy monitoring in parallel to consulting their physician. The intention to use such devices several times daily or weekly, expressed by more than half of the participants, highlights the potential of such technologies.

The impact of a mobile application-based treatment for urinary incontinence in adult women: Design of a mixed-methods randomized controlled trial in a primary care setting

AIMS

We aim to assess whether a purpose-developed mobile application (app) is non-inferior regarding effectiveness and cost-effective when used to treat women with urinary incontinence (UI), as compared to care as usual in Dutch primary care. Additionally, we will explore the expectations and experiences of patients and care providers regarding app usage.

METHODS

A mixed-methods study will be performed, combining a pragmatic, randomized-controlled, non-inferiority trial with an extensive process evaluation. Women aged ≥18 years, suffering from UI ≥ 2 times per week and with access to a smartphone or tablet are eligible to participate. The primary outcome will be the change in UI symptom scores at 4 months after randomization, as assessed by the International Consultation on Incontinence Modular Questionnaire UI Short Form. Secondary outcomes will be the change in UI symptom scores at 12 months, as well as the patient-reported global impression of improvement, quality of life, change in sexual functioning, UI episodes per day, and costs at 4 and 12 months. In parallel, we will perform an extensive process evaluation to assess the expectations and experiences of patients and care providers regarding app usage, making use of interviews, focus group sessions, and log data analysis.

CONCLUSION

This study will assess both the effectiveness and cost-effectiveness of app-based treatment for UI. The combination with the process evaluation, which will be performed in parallel, should also give valuable insights into the contextual factors that influence the effectiveness of such a treatment.

Nursing care by telehealth: what is the influence of distance on communication?

ABSTRACT Objective: Evaluate the perception of nurses regarding interpersonal communication while providing care via telehealth. Method: Qualitative research realized with seven nurses working in telehealth in Brazil, the sample was determined by data saturation. A questionnaire with open questions was applied and then content analysis of the dialogues was conducted, focusing on thematic analysis. Results: Four categories emerged from the dialogues: Understanding the importance of communication; the interpersonal relationship interfering with communication; Communicating via technology; and Learning the communication process. Final considerations: The perception of nurses working in telehealth in Brazil is that technology has facilitated their professional practice; however, in relation to the communication process, they believe it is harder to communicate by telehealth, mainly due to difficulty in perceiving nonverbal signals. To overcome these difficulties, they agreed that interpersonal communication is a skill that must be acquired during their professional training.

Telemedicine is as effective as in-person visits for patients with asthma

BACKGROUND

Access to asthma specialists is a problem, particularly in rural areas, thus presenting an opportunity for management using telemedicine.

OBJECTIVE

To compare asthma outcomes during 6 months in children managed by telemedicine vs in-person visits.

METHODS

Children with asthma residing in 2 remote locations were offered the choice of an in-person visit or a telemedicine session at a local clinic. The telemedicine process involved real-time use of a Remote Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution camera. A telefacilitator operated the RPS and performed diagnostic and educational procedures, such as spirometry and asthma education. Children in both groups were assessed initially, after 30 days, and at 6 months. Asthma outcome measures included asthma control using validated tools (Asthma Control Test, Childhood Asthma Control Test, and Test for Respiratory and Asthma Control in Kids) and patient satisfaction (telemedicine group only). Noninferiority analysis of asthma control was performed using the minimally important difference of an adjusted asthma control test that combined the 3 age groups.

RESULTS

Of 169 children, 100 were seen in-person and 69 via telemedicine. A total of 34 in-person and 40 telemedicine patients completed all 3 visits. All had a small, although statistically insignificant, improvement in asthma control over time. Telemedicine was noninferior to in-person visits. Most of the telemedicine group subjects were satisfied with their experience.

CONCLUSION

Children with asthma seen by telemedicine or in-person visits can achieve comparable degrees of asthma control. Telemedicine can be a viable alternative to traditional in-person physician-based care for the treatment and management of asthma.

Telemedicine in the management of non-acute headaches: A prospective, open-labelled non-inferiority, randomised clinical trial

Objectives We determined headache patients' satisfaction with telemedicine and assessed how telemedicine influenced headache burden, compliance with diagnosis and treatment, and need for follow-up consultations. Methods During 2.5 years, patients from Northern Norway referred with non-acute headaches for a specialist consultation at Tromsø University Hospital were consecutively randomised to either telemedicine or traditional visits. Baseline data were recorded and compared to data from a three-month follow-up questionnaire (see Supplementary material). The following were evaluated: (1) satisfaction with the consultation; (2) headache status; subjective improvement, average pain intensity, treatment, headache days per month, and Headache Impact Test (HIT-6); and (3) treatment compliance and follow-up visits. Results Out of 402 consultations, 348 (86.6%) answered the questionnaire. Satisfaction was similar in the telemedicine and the traditional group (88.8% vs. 92.3%; p = 0.35). Subgroup analyses were not prespecified, but there were no differences in satisfaction among females, migraineurs, rural patients and urban patients. Improvement from baseline after three months was reported equally in the telemedicine and the traditional groups. There were also no differences in treatment compliance, but rural telemedicine patients had less-frequent headache visits at three months' follow-up (28.9% vs. 48.7%, p = 0.002). Conclusion Telemedicine is non-inferior to traditional consultations in patient satisfaction, specialist evaluation, and treatment of non-acute headaches. ClinicalTrials.gov ID: NCT02270177.

Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives

BACKGROUND

A novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives.

METHODS/DESIGN

The longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services.

DISCUSSION

It is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines.

Telemedicine: Pediatric Applications

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

Internet-based questionnaire to self-assess autonomy and obtain a life-at-home services enforcement plan: a retrospective validation study

BACKGROUND

In France, a specially-designed care plan for the elderly is generally based on an interdisciplinary, complex and time-consuming process. The health system assigns care throughout the social and health care services using multiple providers and sites.

OBJECTIVE

The free website www.jesuisautonome.fr offers senior citizens and their families an opportunity to assess their own independence at home using a questionnaire in order to obtain a personal, life-at-home, enforcement plan. We aim to examine the correlation between the specially-designed care plan obtained by the usual assessment method and through self-evaluation via the website.

METHODS

Community-dwelling subjects, consulting for the first time from December 2012 to July 2014, were under consideration. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) and also independently during the first consultation; patients and their caregivers were then asked to fill out the questionnaire on the website. The two methods were compared using the Bland-Altman analysis for quantitative values and Kappa values for qualitative values.

RESULTS

73 patients completed the study. Correlation was excellent between parameters that did not include error due to risk to the patient (assistance with bathing and dressing, a nurse for drug distribution, measure of legal protection). Correlation was good with housekeeper hours that involved a financial cost to state social services and families. The GIR (Iso Ressource Groupe), which in France serves as a reference to determine social disability of the elderly, was similar.

CONCLUSION

Our study confirms the potential of the website www.jesuisautonome.fr. to improve the delivery of health and social care services.