Time Gain Needed for In-Ambulance Telemedicine: Cost-Utility Model

Can drones save lives and money? An economic evaluation of airborne delivery of automated external defibrillators

BACKGROUND

Out-of-hospital cardiac arrest is one of the most frequent causes of death in Europe. Emergency medical services often struggle to reach the patient in time, particularly in rural areas. To improve outcome, early defibrillation is required which significantly increases neurologically intact survival. Consequently, many countries place Automated External Defibrillators (AED) in accessible public locations. However, these stationary devices are frequently not available out of hours or too far away in emergencies. An innovative approach to mustering AED is the use of unmanned aerial systems (UAS), which deliver the device to the scene.

METHODS

This paper evaluates the economic implications of stationary AED versus airborne delivery using scenario-based cost analysis. As an example, we focus on the rural district of Vorpommern-Greifswald in Germany. Formulae are developed to calculate the cost of stationary and airborne AED networks. Scenarios include different catchment areas, delivery times and unit costs.

RESULTS

UAS-based delivery of AEDs is more cost-efficient than maintaining traditional stationary networks. The results show that equipping cardiac arrest hot spots in the district of Vorpommern-Greifswald with airborne AEDs with a response time < 4 min is an effective method to decrease the time to the first defibrillation The district of Vorpommern-Greifswald would require 45 airborne AEDs resulting in annual costs of at least 1,451,160 €.

CONCLUSION

In rural areas, implementing an UAS-based AED system is both more effective and cost-efficient than the conventional stationary solution. When regarding urban areas and hot spots of OHCA, complementing the airborne network with stationary AEDs is advisable.

Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

BACKGROUND

Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT.

METHODS

A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality.

RESULTS

Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%).

CONCLUSIONS

A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.

Telemedical emergency services: central or decentral coordination?

BACKGROUND AND OBJECTIVE

Teleemergency doctors support ambulance cars at the emergency site by means of telemedicine. Currently, each district has its own teleemergency doctor office (decentralized solution). This paper analyses the advantages and disadvantages of a centralized solution where several teleemergency doctors work in parallel in one office to support the ambulances in more districts.

METHODS

The service of incoming calls from ambulances to the teleemergency doctor office can be modelled as a queuing system. Based on the data of the district of Vorpommern-Greifswald in the Northeast of Germany, we assume that arrivals and services are Markov chains. The model has parallel channels proportionate to the number of teleemergency doctors working simultaneously and the number of calls which one doctor can handle in parallel. We develop a cost function with variable, fixed and step-fixed costs.

RESULTS

For the district of Greifswald, the likelihood that an incoming call has to be put on hold because the teleemergency doctor is already fully occupied is negligible. Centralization of several districts with a higher number of ambulances in one teleemergency doctor office will increase the likelihood of overburdening and require more doctors working simultaneously. The cost of the teleemergency doctor office per ambulance serviced strongly declines with the number of districts cooperating.

DISCUSSION

The calculations indicate that centralization is feasible and cost-effective. Other advantages (e.g. improved quality, higher flexibility) and disadvantages (lack of knowledge of the location and infrastructure) of centralization are discussed.

CONCLUSIONS

We recommend centralization of telemedical emergency services. However, the number of districts cooperating in one teleemergency doctor office should not be too high and the distance between the ambulance station and the telemedical station should not be too large.

Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond

BACKGROUND

Evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the COVID-19 era.

OBJECTIVE

To conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. Additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience.

METHODS

A systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. We reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty.

RESULTS

A total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. A total of 13 studies were conducted in the United States and 39 in foreign countries. Patient management was successful via telemedicine in 99.6% of cases. Telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. A total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. From 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). About 94.3% of telemedicine visits were billed using face-to-face procedural codes.

CONCLUSION

Neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics.

The Experience of Using Video Support in Ambulance Care: An Interview Study with Physicians in the Role of Regional Medical Support

Background: In order to facilitate more effective patient assessment and diagnostic support by improving the flow of information between ambulance nurses (AN) and physicians in the role of regional medical support (RMS), an application was developed for transmitting real-time video images. Objective: The objective of this study was to elucidate the physicians’ experiences using a video application to support the assessment and triage procedure in ambulance care, when patients are deemed to not have an urgent need for emergency care. Design: The design for this research was a qualitative interview study. Ten physicians, working as RMS in ambulance care, were purposively selected to participate. The telemedicine concept studied consisted of a real-time video image application, in addition to the currently used mobile phone. When a patient was deemed eligible for inclusion in the study, the ambulance nurse (AN) contacted the RMS via telephone to initiate a video consultation. To elucidate the RMS experience of using the application, a conventional content analysis was performed. Results: The main theme “a feeling of being satisfied through a sense of increased patient safety” emerged from the following two categories: adds value in diagnosing situations (three subcategories, i.e., support in diagnosing, usability, and technical weakness) and increase communication opportunities (four subcategories, i.e., assessing the level of care, patient dialogue, professional communication, and team learning). Conclusions: Physicians in the role of RMS experienced a positive impact using video image transmission in addition to the currently used mobile phone. This evaluation was derived from a sense of increased patient safety in the assessment situation when patients were considered to be triaged to self-care.

Evaluation of a Rural Emergency Medical Service Project in Germany: Protocol for a Multimethod and Multiperspective Longitudinal Analysis

BACKGROUND

German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases.

OBJECTIVE

The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services.

METHODS

We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes.

RESULTS

We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018.

CONCLUSIONS

Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons' individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14358.

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.