A Multidisciplinary Intervention Utilizing Virtual Communication Tools to Reduce Health Disparities: A Pilot Randomized Controlled Trial

Associations Between Telemedicine Use Barriers, Organizational Factors, and Physician Perceptions of Care Quality

Introduction: Evaluating physician perceptions of telemedicine use and its impact on care quality among physician providers is critical to sustaining telemedicine programs, given the uncertainty of reimbursement policy, preferences, inadequate training, and technical difficulties. Physicians reported technical barriers to effectively practicing integrated medicine using telemedicine as patient volumes increased during the pandemic. The objective of this work was to examine whether perceived practice barriers and facilitators were associated with physician respondents' perceptions of telemedicine care quality compared with in-person care. Methods: This cross-sectional study analyzed the 2021 National Electronic Health Record Survey. The sample comprised 1,857 nonfederally employed physicians (weighted n = 403,013) delivering integrated patient care. Of those physicians, 1,630 (weighted n = 346,646) reported providing care through telemedicine. We reported frequencies and percentages of reported practice characteristics. Generalized ordinal logistic regressions examined relationships between practice factors and care quality for telemedicine care. Results: Most of the sample (n = 1,630) were male (66.1%), >50 years of age (66.1%), and worked in a single location (73.5%). A total of 70% of respondents reported that patients had difficulty using telemedicine platforms, and 64% reported limitations in patients' access to technology. Most respondents indicated having provided quality care to some extent (45%) and to a great extent (26%) during telemedicine visits compared to in-person visits. Associations between barriers, facilitators, and care quality perceptions were positive, underscoring resiliency in telemedicine programs among practices. Conclusion: Care modalities and the organizational, environmental, and personal facilitators drive quality perceptions among physicians. Perceived fit and usability determine perceptions of care quality for providers integrating telemedicine into their practice.

Population health interventions for cardiometabolic diseases in primary care: a scoping review and RE-AIM evaluation of current practices

Introduction

Cardiometabolic diseases (CMD) are the leading cause of death in high-income countries and are largely attributable to modifiable risk factors. Population health management (PHM) can effectively identify patient subgroups at high risk of CMD and address missed opportunities for preventive disease management. Guided by the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework, this scoping review of PHM interventions targeting patients in primary care at increased risk of CMD aims to describe the reported aspects for successful implementation.

Methods

A comprehensive search was conducted across 14 databases to identify papers published between 2000 and 2023, using Arksey and O'Malley's framework for conducting scoping reviews. The RE-AIM framework was used to assess the implementation, documentation, and the population health impact score of the PHM interventions.

Results

A total of 26 out of 1,100 studies were included, representing 21 unique PHM interventions. This review found insufficient reporting of most RE-AIM components. The RE-AIM evaluation showed that the included interventions could potentially reach a large audience and achieve their intended goals, but information on adoption and maintenance was often lacking. A population health impact score was calculated for six interventions ranging from 28 to 62%.

Discussion

This review showed the promise of PHM interventions that could reaching a substantial number of participants and reducing CMD risk factors. However, to better assess the generalizability and scalability of these interventions there is a need for an improved assessment of adoption, implementation processes, and sustainability.

Exploring the coach-client interaction of virtual health coaching conducted in patients with type 2 diabetes mellitus: A scoping review

BACKGROUND AND AIMS

Recent studies reported that virtual health coaching (VHCs) had greater benefits on glycemic control compared to traditional diabetes care. However, VHCs are reported to lack real-time evaluations and personalized patient feedback. To support the intention of developing high quality VHC programs, this review aimed to describe characteristics of the coach-client interaction within VHC that had beneficial impacts on patients with type 2 diabetes mellitus (T2DM) patients.

METHODS

We conducted a comprehensive scoping review following the six steps of the framework developed by Arksey and O'Malley. Twelve articles that met the eligibility criteria were retrieved from Medline, ProQuest, Science Direct and Scopus.

RESULTS

We found five key concepts regarding the characteristics of coach-client interactions. First, the discussion through smartphones involved individualized feedback and insights, goals setting, barrier identification, facilitation to change behavior, and also clients' clinical, mental, and social conditions. Second, the interactions were supported by in-app features including in-app messaging, email, in-app live video consultation and in-app discussion forums. Third, the most used time of evaluation was 12 months. Fourth, the most commonly delivered topic was lifestyle changes which were predominantly focused on dietary patterns. Fifth, most of health coaches were health liaisons.

CONCLUSIONS

The findings highlight the discussion points within interaction through well-planned devices combining an appropriate in-app features contribute to an effective coach-client interactions of VHC. It is expected that future studies can apply these findings as the basis to develop a single set of standards for VHCs which refer to specific patterns of patient-oriented interaction.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Physicians' satisfaction with telehealth services among family physicians in Cluster 1 hospitals

Background

Physicians are increasingly applying telehealth services in the hospital. The use of telehealth services helps to ensure that doctors treat patients and write prescriptions remotely without the need to meet physically with the patient.

Methods

The study used a descriptive survey design, in which collection and sampling of data were standardized to represent the population of all physicians. The target population was all doctors in all private healthcare systems, King Saud Medical City (KSMC), and four hospitals in the southwest area of Saudi Arabia. Data were collected via a simple random sampling system and engaged questionnaires. Microsoft Office Excel was used for data entry and preparation of graphs and charts.

Results

We collected data from 151 physicians in Cluster 1 hospitals. Most were males (74.8%) with a mean age of 31.14 years. Of these, 57.6% thought that telemedicine saved physicians' traveling time, 27.8% were satisfied with telemedicine services, 28.5% were not satisfied, and 43.7% were neutral; 61.6% thought that telemedicine was important for them, and 53.6% liked using telemedicine because of the similarity of participants' values and society values underlying its uses; 59.6% reported that telemedicine improved their job effectiveness and performance, while 58.9% reported that telemedicine enabled them to accomplish tasks more quickly and made them more productive.

Conclusion

Physicians expressed a high level of satisfaction and a positive attitude toward telemedicine. Future researches are essential to see how attitudes about telemedicine have altered since the pandemic.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Patient Centered Studies Focused on Type 2 Diabetes Management, Education, and Family Support: A Scoping Review

BACKGROUND

Although a large amount of research has been conducted in diabetes management, many of the articles do not focus on patient-centered questions and concerns. To address this shortcoming, patients and various other stakeholders from three northern Mississippi communities co-created research questions focused on Type 2 diabetes management.

OBJECTIVE

To identify the diabetes management literature pertaining to each of the six patient-developed research questions from March 2010 to July 2020.

METHODS

A scoping review was conducted via PubMed to identify research articles from March 2010 to July 2020 focused on patient-centered Type 2 diabetes studies relevant to the six research questions.

RESULTS

A total of 1,414 studies were identified via the search strategy and 34 were included for qualitative analysis following article exclusion. For one of the research questions, there were no articles included. For the remaining research questions, the number of articles identified ranged from two to eleven. After analysis of the included articles, it was found that these questions either lacked extensive data or had not been implemented in the practice of diabetes management.

CONCLUSION

Additional research is warranted for three of the five questions, as current evidence is either lacking or contradictory. In the remaining two questions, it seems that adequate current research exists to warrant transitioning to implementation focused studies wherein data may be generated to improve sustainability and scaling of current programming.

Remote Monitoring Systems for Patients With Chronic Diseases in Primary Health Care: Systematic Review

Background

The digital age, with digital sensors, the Internet of Things (IoT), and big data tools, has opened new opportunities for improving the delivery of health care services, with remote monitoring systems playing a crucial role and improving access to patients. The versatility of these systems has been demonstrated during the current COVID-19 pandemic. Health remote monitoring systems (HRMS) present various advantages such as the reduction in patient load at hospitals and health centers. Patients that would most benefit from HRMS are those with chronic diseases, older adults, and patients that experience less severe symptoms recovering from SARS-CoV-2 viral infection.

Objective

This paper aimed to perform a systematic review of the literature of HRMS in primary health care (PHC) settings, identifying the current status of the digitalization of health processes, remote data acquisition, and interactions between health care personnel and patients.

Methods

A systematic literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify articles that explored interventions with HRMS in patients with chronic diseases in the PHC setting.

Results

The literature review yielded 123 publications, 18 of which met the predefined inclusion criteria. The selected articles highlighted that sensors and wearables are already being used in multiple scenarios related to chronic disease management at the PHC level. The studies focused mostly on patients with diabetes (9/26, 35%) and cardiovascular diseases (7/26, 27%). During the evaluation of the implementation of these interventions, the major difficulty that stood out was the integration of information into already existing systems in the PHC infrastructure and in changing working processes of PHC professionals (83%).

Conclusions

The PHC context integrates multidisciplinary teams and patients with often complex, chronic pathologies. Despite the theoretical framework, objective identification of problems, and involvement of stakeholders in the design and implementation processes, these interventions mostly fail to scale up. Despite the inherent limitations of conducting a systematic literature review, the small number of studies in the PHC context is a relevant limitation. This study aimed to demonstrate the importance of matching technological development to the working PHC processes in interventions regarding the use of sensors and wearables for remote monitoring as a source of information for chronic disease management, so that information with clinical value is not lost along the way.

Understanding Physicians' Preferences for Telemedicine During the COVID-19 Pandemic: Cross-sectional Study

BACKGROUND

In contrast to the current broad dissemination of telemedicine across medical specialties, previous research focused on the effectiveness of telemedicine in special populations and for behavioral health encounters, demonstrating that both physician and patient factors impact the efficacious use of telemedicine.

OBJECTIVE

We aim to evaluate physician perceptions of the appropriateness of telemedicine for patients attending the primary care practices of a federally qualified health center in New York City.

METHODS

We used an anonymous cross-sectional survey including closed- and open-ended questions. We used chi-square to test whether providers from certain specialties were more likely to state they would use telemedicine in the future. We used t tests to compare age between those who would versus would not use telemedicine. We then used logistic regression to test whether age and specialty were both correlated with the desire to use telemedicine in the future. We used thematic content analysis to describe the reasons providers felt they would not want to use telemedicine in the future and to describe the situations for which they felt telemedicine would be appropriate.

RESULTS

Of 272 health care providers who were sent the electronic survey, 157 (58%) responded within the 2-week survey time frame. The mean age of providers was 45 (range 28-75) years. Overall, 80% (126/157) stated they would use telemedicine in the future. Compared to the family medicine, internal medicine, behavioral health, dental, and obstetrics and gynecology specialties, providers from pediatrics, med-peds, subspecialties, and surgery (protelemedicine specialties) were more likely to believe telemedicine would be useful post pandemic (61/67 [91%] vs 65/90 [72%]; P<.001). Providers who reported they would use telemedicine in the future were younger (mean age 44, range 42-46 years vs mean age 50, range 46-55 years; P=.048). In the regression analysis, both protelemedicine specialties and age were significantly associated with odds of reporting they would use telemedicine in the future (prospecialties: odds ratio 5.2, 95% CI 1.7-16.2; younger age: odds ratio 1.05, 95% CI 1.01-1.08). Providers who did not want to use telemedicine in the future cited concerns about inadequate patient care, lack of physical patient interaction, technology issues, and lack of necessity. Providers who felt telemedicine would be useful cited the following situations: follow-up visits, medication refills, urgent care, patient convenience, and specific conditions such as behavioral health, dermatology visits, and chronic care management.

CONCLUSIONS

The majority of health providers in this resource-limited setting in a federally qualified health center believed that telemedicine would be useful for providing care after the pandemic is over.

The Patient-centered Medical Home as an Intervention Strategy for Diabetes Mellitus: A Systematic Review of the Literature

BACKGROUND

Poorly managed diabetes mellitus increases health care expenditures and negatively impacts health outcomes. There are 34 million people living with diabetes in the United States with a direct annual medical cost of $237 billion. The patient-centered medical home (PCMH) was introduced to transform primary care by offering team-based care that is accessible, coordinated, and comprehensive. Although the PCMH is believed to address multiple gaps in delivering care to people living with chronic diseases, the research has not yet reported clear benefits for managing diabetes.

OBJECTIVE

The study reviews the scientific literature about diabetes mellitus outcomes reported by PCMHs, and understands the impact of team-based care, interdisciplinary communication, and care coordination strategies on the clinical, financial, and health-related outcomes.

METHODS

The systematic review was performed according to the Cochrane method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight databases were systematically searched for articles. The Oxford Centre for Evidence-based Medicine Levels of evidence and the Critical Appraisal Skills Programme systematic review checklist were used to evaluate the studies.

RESULTS

The search resulted in 596 articles, of which 24 met all the inclusion criteria. Care management resulted in more screenings and better preventive care. Pharmacy-led interventions and technology were associated with positive clinical outcomes, decreased utilization, and cost savings. Most studies reported decreased emergency room visits and less inpatient admissions.

CONCLUSION

The quality and strength of the outcomes were largely inconclusive about the overall effectiveness of the PCMH. Defining and comparing concepts across studies was difficult as universal definitions specific to the PCMH were not often applied. More research is needed to unpack the care model of the PCMH to further understand how the individual key components, such as care bundles, contribute to improved outcomes. Further evaluations are needed for team-based care, communication, and care coordination with comparisons to patient, clinical, health, and financial outcomes.

Attitudes of the Public to Receiving Medical Care during Emergencies through Remote Physician-Patient Communications

Providing health services through remote communications for sub-acute health issues during emergencies may help reduce the burden of the health care system and increase availability of care. This study aimed to investigate the attitudes of the public towards receiving medical services and providing medical information through remote communication in times of emergencies. During the pandemic outbreak of the novel coronavirus (COVID-19), pandemic outbreak, 507 participants answered a structured online survey, rating their mean willingness to receive medical care and provide medical information, on a four-point Likert scale. Furthermore, demographic characteristics, social media use, and trust in data protection was collected. The mean willingness to receive medical services was 3.1 ± 0.6 and the mean willingness to provide medical information was 3.0 ± 0.7, with a strong significant correlation between the two (r = 0.76). The multiple regression model identified higher trust in data protection, level of education, and social media use as statistically significant predictors for a higher willingness to receive medical information while the first two predicted willingness to provide information. The findings suggest an overall positive attitude to receive medical care through remote communications.

Role of Telemedicine in Multidisciplinary Team Meetings

We reviewed the role of telemedicine in multidisciplinary team (MDT) meetings, which play an important role in the provision of effective and tailored patient care in diverse clinical settings. This article is based on conducted search in PubMed. Search terms included “telemedicine,” “multidisciplinary team,” and “(telemedicine) and (multidisciplinary team).” Telemedicine provides an important advantage in the provision of MDT meeting comparing with traditional settings. Those include improved access to and collaboration of medical experts. This resulted in increased levels of medical competence and improved provisions of diagnosis, treatment, and follow-up to patients irrespective of location.

Bridging Gaps and Understanding Disparities in Gestational Diabetes Mellitus to Improve Perinatal Outcomes

IN BRIEF For a woman who is facing financial, cultural, psychological, or social challenges, discovering that she has gestational diabetes mellitus (GDM) represents a significant burden. By better understanding challenges underserved women with GDM face, multidisciplinary clinical teams can make essential changes in health care delivery to optimize outcomes not just during pregnancy, but also, equally importantly, beyond pregnancy to prevent long-term disease.